BARIATRIC SURGERY

Introduction

Bariatric =Baros heavinesslargepressure It is the field of medicine encompassing the study of

obesity its causes prevention and treatment

Bariatric surgery A therapeutic intervention to understand and treat the cause and sequelae of morbid obesity

Bariatric Surgery

Number of procedures performed has increased 10-fold 14000 in 1993 140000 in 2004 gt 200000 in 2005 gt 300000 in 2007

introductionObesity is a physiologic

dysfunction of the human organism with environmental genetic and endocrinologic causes and a major health problem with clearly established health implications

Body mass index (BMI) is a simple index of weight-for-height that is commonly used to classify overweight and obesity in adults

Defined as a persons weight in kilograms divided by the square of his height in meters (kgm2)

Degrees of Obesity

NORMAL BMI 185 ndash 249

OVERWEIGHTBMI 25 ndash 299

OBESEBMI 30 ndash 349

SEVERE OBESEBMI 35 ndash 399

MORBIDLY OBESEBMI 40

Obesity grading and assessment in Western and Asian PopulationBMIAverageOverweight

ObeseMorbidly

Obese

Western20-24925-29930-40gt40

Asian18-22923-277275-374gt375

Prevalence of Obesity

As per WHOrsquos The World health statistics 2012 report one in six adults obese one in 10 diabetic and one in three has raised blood pressure

Obesity has reached epidemic proportions in India in the 21st century with morbid obesity affecting 5 of the countrys population

Introduction

Bariatric =Baros heavinesslargepressure It is the field of medicine encompassing the study of

obesity its causes prevention and treatment

Bariatric surgery A therapeutic intervention to understand and treat the cause and sequelae of morbid obesity

Bariatric Surgery

Number of procedures performed has increased 10-fold 14000 in 1993 140000 in 2004 gt 200000 in 2005 gt 300000 in 2007

introductionObesity is a physiologic

dysfunction of the human organism with environmental genetic and endocrinologic causes and a major health problem with clearly established health implications

Body mass index (BMI) is a simple index of weight-for-height that is commonly used to classify overweight and obesity in adults

Defined as a persons weight in kilograms divided by the square of his height in meters (kgm2)

Degrees of Obesity

NORMAL BMI 185 ndash 249

OVERWEIGHTBMI 25 ndash 299

OBESEBMI 30 ndash 349

SEVERE OBESEBMI 35 ndash 399

MORBIDLY OBESEBMI 40

Obesity grading and assessment in Western and Asian PopulationBMIAverageOverweight

ObeseMorbidly

Obese

Western20-24925-29930-40gt40

Asian18-22923-277275-374gt375

Prevalence of Obesity

As per WHOrsquos The World health statistics 2012 report one in six adults obese one in 10 diabetic and one in three has raised blood pressure

Obesity has reached epidemic proportions in India in the 21st century with morbid obesity affecting 5 of the countrys population

Bariatric Surgery

Number of procedures performed has increased 10-fold 14000 in 1993 140000 in 2004 gt 200000 in 2005 gt 300000 in 2007

introductionObesity is a physiologic

dysfunction of the human organism with environmental genetic and endocrinologic causes and a major health problem with clearly established health implications

Body mass index (BMI) is a simple index of weight-for-height that is commonly used to classify overweight and obesity in adults

Defined as a persons weight in kilograms divided by the square of his height in meters (kgm2)

Degrees of Obesity

NORMAL BMI 185 ndash 249

OVERWEIGHTBMI 25 ndash 299

OBESEBMI 30 ndash 349

SEVERE OBESEBMI 35 ndash 399

MORBIDLY OBESEBMI 40

Obesity grading and assessment in Western and Asian PopulationBMIAverageOverweight

ObeseMorbidly

Obese

Western20-24925-29930-40gt40

Asian18-22923-277275-374gt375

Prevalence of Obesity

As per WHOrsquos The World health statistics 2012 report one in six adults obese one in 10 diabetic and one in three has raised blood pressure

Obesity has reached epidemic proportions in India in the 21st century with morbid obesity affecting 5 of the countrys population

introductionObesity is a physiologic

dysfunction of the human organism with environmental genetic and endocrinologic causes and a major health problem with clearly established health implications

Body mass index (BMI) is a simple index of weight-for-height that is commonly used to classify overweight and obesity in adults

Defined as a persons weight in kilograms divided by the square of his height in meters (kgm2)

Degrees of Obesity

NORMAL BMI 185 ndash 249

OVERWEIGHTBMI 25 ndash 299

OBESEBMI 30 ndash 349

SEVERE OBESEBMI 35 ndash 399

MORBIDLY OBESEBMI 40

Obesity grading and assessment in Western and Asian PopulationBMIAverageOverweight

ObeseMorbidly

Obese

Western20-24925-29930-40gt40

Asian18-22923-277275-374gt375

Prevalence of Obesity

As per WHOrsquos The World health statistics 2012 report one in six adults obese one in 10 diabetic and one in three has raised blood pressure

Obesity has reached epidemic proportions in India in the 21st century with morbid obesity affecting 5 of the countrys population

Body mass index (BMI) is a simple index of weight-for-height that is commonly used to classify overweight and obesity in adults

Defined as a persons weight in kilograms divided by the square of his height in meters (kgm2)

Degrees of Obesity

NORMAL BMI 185 ndash 249

OVERWEIGHTBMI 25 ndash 299

OBESEBMI 30 ndash 349

SEVERE OBESEBMI 35 ndash 399

MORBIDLY OBESEBMI 40

Obesity grading and assessment in Western and Asian PopulationBMIAverageOverweight

ObeseMorbidly

Obese

Western20-24925-29930-40gt40

Asian18-22923-277275-374gt375

Prevalence of Obesity

As per WHOrsquos The World health statistics 2012 report one in six adults obese one in 10 diabetic and one in three has raised blood pressure

Obesity has reached epidemic proportions in India in the 21st century with morbid obesity affecting 5 of the countrys population

Degrees of Obesity

NORMAL BMI 185 ndash 249

OVERWEIGHTBMI 25 ndash 299

OBESEBMI 30 ndash 349

SEVERE OBESEBMI 35 ndash 399

MORBIDLY OBESEBMI 40

Obesity grading and assessment in Western and Asian PopulationBMIAverageOverweight

ObeseMorbidly

Obese

Western20-24925-29930-40gt40

Asian18-22923-277275-374gt375

Prevalence of Obesity

As per WHOrsquos The World health statistics 2012 report one in six adults obese one in 10 diabetic and one in three has raised blood pressure

Obesity has reached epidemic proportions in India in the 21st century with morbid obesity affecting 5 of the countrys population

Obesity grading and assessment in Western and Asian PopulationBMIAverageOverweight

ObeseMorbidly

Obese

Western20-24925-29930-40gt40

Asian18-22923-277275-374gt375

Prevalence of Obesity

As per WHOrsquos The World health statistics 2012 report one in six adults obese one in 10 diabetic and one in three has raised blood pressure

Obesity has reached epidemic proportions in India in the 21st century with morbid obesity affecting 5 of the countrys population

Prevalence of Obesity

As per WHOrsquos The World health statistics 2012 report one in six adults obese one in 10 diabetic and one in three has raised blood pressure

Obesity has reached epidemic proportions in India in the 21st century with morbid obesity affecting 5 of the countrys population

374 53242

180 29665

552 66220

266 51794

121 23998

587 101072

767 112847

World 2010 = 285 million 2030 = 438 million

Increase 54

Global projections for the diabetes epidemic 2010-2030 (millions)

Bariatric Surgical and Procedural Interventions in the Treatment of Obese Patients with Type 2 Diabetes

The Toxic Environment

Etiology of Obesity

Debate is ongoing regarding the relative Genetic Vs Environmental components of the disease Clear familial predisposition Specific Genes Hundreds of genetic loci have been associated experimentally to obesity in the so-called

Human Obesity Gene Map

1) FTO-Fat mass and Obesity-related gene

2) MC4R-Melanocortin 4 receptor gene

Associated with obesity increased fat mass and insulin resistance Thrifty Gene Hypothesis During human development thrifty gene allowed for more efficient absorption

and use of the calories ingested However in modern society it helps increase the intake of calories in excess of metabolic needs

Role of genes versus environment

Pathophysiology Of Obesity

Obesity can result from increased energy intake decreased energy expenditure or a combination of the two

The severely obese individual has in general persistent hunger that is not satiated by amounts of food that satisfy the non-obese

This lack of satiety or maintenance of satiety may be the single most important factor in the process

Nutrient ingestion into the stomach or proximal intestine elicits hormonal signals that release neuropeptides which in turn alter body metabolism

Hormones Leptin and Ghrelin are appetite stimulant orexigenic Insulin and Cholecystokinin are anorexic

Obesity Related Co-Morbidities

Co-Morbidity Diabetes Hypertension Hyperlipidemia Cardiac disease Respiratory disease Obstructive sleep apnea Arthritis Depression Stress Incontinence Joint problems

Occurrence in the Obese 14ndash20 25ndash55 35ndash53 10ndash15

10ndash20 20ndash25 70ndash90 50 50

Pulmonary diseaseabnormal functionobstructive sleep apneahypoventilation syndrome

Nonalcoholic fatty liver diseasesteatosissteatohepatitiscirrhosis

Coronary heart disease Diabetes Dyslipidemia Hypertension

Gynecologic abnormalitiesabnormal mensesinfertilitypolycystic ovarian syndrome

Osteoarthritis

Skin

Gall bladder disease

Cancerbreast uterus cervixcolon esophagus pancreaskidney prostate

Phlebitisvenous stasis

Gout

Medical Complications of Obesity Idiopathic intracranial

hypertensionStroke

Cataracts

Severe pancreatitis

What are your optionsSource Adkinson Am J Clinical Nutrition 1994

1 Diet Exercise Behavioral Changes -up to 10 loss of excess body weight -ineffective long-term less than 5 sustain significant weight loss2 Weight Loss Drugs -minimal sustained weight loss -side effects prevent long-term use3 Weight-Loss Surgery -55 to 75 loss of excess body weight

Guidelines for the Treatment of Overweight and Obese Individuals

Indications for drug treatment

Pharmacological treatments are typically used as an adjunct to diet and exercise for patients with BMI of 30 or greater BMI of ge27 for patients with obesity-related risk factors or

comorbid diseases

Obesity Drugs Appetite suppressants

Noradrenergic (Schedule IV) Phentermine (Adipex Fastin) Diethylpropion (Tenuate)

Noradrenergic (Schedule III) Benzphetamine (Didrex) Phendimetrazine (Bontril)

Serotonergic Fenfluramine dexfenfluramine

Mixed Noradrenergic amp Serotonergic Sibutramine (Meridia)

Nutrient absorption reducers Lipase inhibitor

Orlistat (Xenical)

Sibutramine (Meridia)

Blocks presynaptic receptor uptake of norepinephrine and serotonin thereby potentiating their anorexic effect in the central nervous system

Contraindicated CAD CHF cardiac arrhythmias or stroke Side Effects hypertension arrhythmia tachycardia headache dry

mouth constipation insomnia

Orlistat

Inhibits pancreatic lipase and thereby reduces absorption of up to 30 of ingested dietary fat

Lipase inhibitor reduces fat absorption by ~30 resulting in reduction in energy intake

Inhibits digestion of dietary triglycerides decreases absorption of cholesterol and lipid-soluble vitamins

Side Effects

GI side effects due to inhibition of fat absorption pain fecal urgency liquid stools flatulence with discharge

oily spotting

Why Diets Often Fail

Require lot of time and energy

Cause feelings of deprivation

Donrsquot address why people overeat

Disrupt metabolism

Why SurgeryDiet and exercise are not effective

long term in the morbidly obese Surgery is an accepted and effective approach Medical co-morbidities are improvedresolved Increases life expectancy Decreases health care costs Surgical risk is acceptable vs risk of long-term obesity

RESOLUTION OF DISEASES FOLLOWING BARIATRIC SURGERY

Who Is a Surgical Candidate BMI gt 40 kgm2

-OR- BMI gt 35 kgm2 and major medical complications of

obesity-AND-

Failure of other approaches to long-term weight loss Age 18-55(relative)

Recommended BMI values for Bariatric Surgery in Asians

BMI ge 375

BMI ge 325 with two

associated co-

morbidities

No endocrine cause of obesity Acceptable operative risk Understands surgery and risks Absence of drug or alcohol problem No uncontrolled psychological conditions Consensus after bariatric team

evaluation SurgeonDieticianPsychologistConsultant

Dedicated to life-style change and follow-up

Obesity multidisciplinary team

Surgeon Physician Anesthetist Dietician Specialist bariatric nurse Skilled theatre staff Psychiatrist

Bariatric Surgery and Diabetes

International Diabetes Federation (2011) Journal of Diabetes (3(2011) 261-264) ldquoBariatric surgery is an appropriate treatment of people with T2D and

obesity who are not achieving recommended treatment targets with existing medical therapies especially in the presence of other major comorbiditiesrdquo

lt1 of those eligible actually have WLS for diabetes

Contraindications

Factors that may be considered contraindications include unstable CAD uncontrolled severe OSA uncontrolled psychiatric disorder mental retardation (IQ lt 60) inability to understand the surgery perceived inability to adhere to postoperative restrictions continued drug abuse malignancy with a poor 5-year survival prognosis Cirrhotic liver disease with portal hypertension

Preoperative EvaluationAttention should focus on issues unique to the obese patient

particularly cardiorespiratory status and the airwayConsideration of co morbidities ie hypertension diabetes heart

failure IHD obesity-hypoventilation syndrome metabolic syndrome etc

Results of the sleep study History of previous surgeries their anesthetic challenges need for

ICU admissionCurrent medicationsPatients scheduled for repeat bariatric surgery should be screened

preoperatively for long-term metabolic and nutritional abnormalities

Investigationshellip Recommended preoperative laboratory evaluations include

fasting blood glucose lipid profile electrolytes serum chemistries (to evaluate renal and hepatic function) complete blood count Serum ferritin vitamin B12 thyrotropin amp 25-hydroxyvitamin D

(Miller 7th edition- anesthesia for Bariatic Surgery) ABG measurements help evaluate ventilation as well as the need for perioperative oxygen administration and

postoperative ventilation Routine pulmonary function tests and liver function tests are not cost-effective in asymptomatic obese patients Coaugulation profile ( liver problem repeat surgery orlistat) ECG echocardiography Sleep study if suspected OSA

(Barash 6th edition anesthesia and obesity)

Concurrent Preoperative and Prophylactic Medications

Patients usual medications should be continued until the time of surgery with the possible exception of insulin and oral hypoglycemics

Antibiotic prophylaxis is usually indicated

Obesity itself does not increase the risk for aspiration acid aspiration prophylaxis including H2 receptor agonists or proton pump inhibitors must be considered in patients with identifiable risk for aspiration

Anxiolysis and prophylaxis against deep vein thrombosis (DVT) should be addressed at premedication

DVT consideration Morbid obesity is a major independent risk factor for sudden death from

acute postoperative pulmonary embolism Subcutaneous heparin 5000 IU administered before surgery and repeated every 8 to 12

hours until the patient is fully mobile reduces the risk of DVT LMWH can also be used

Preoperative prophylactic placement of an inferior vena cava filter should be considered in venous stasis disease BMI ge60 truncal obesity and OSA

What Are the Risks

MAJOR RISKS Death (1 of patients die within 30 days) Severe malnutrition (anemia PEM osteomalacia) Peritonitis (from leakage or ruptures at staple sites)

or other infection Obstructions caused by scar tissue in the stomach or

bowels

MINOR RISKS Dumping Syndrome (unpleasant but not harmful) Diarrhea and malodorous gas production Lactose intolerance Hair loss (short-term post-surgery) May have to eventually undergo surgical revision Pain post-surgery

History of Bariatric Surgery

Obesity surgery is not a new discipline The earliest Bariatric procedure performed was in 1954 at Minnesota The procedure

was Jejuno-ileal bypass In 1966Gastric Bypass was introduced as a surgical procedure for weight loss at the

University of Iowa In 1977Griffen reported the first Roux-en-Y Gastric Bypass In 1980surgeons with a more conservative approach developed the Vertical Banded

Gastroplasty Other procedures with longer intestinal segment bypass were also introduced such as

Biliopancreatic Diversions These complex procedures are recommended in super-obese patients ie BMIgt60

How does surgery work

RESTRICTIVE - RESTRICT AMOUNT OF FOOD INGESTED Decreases appetitehunger

Early satiety Behavior modification Gastric Banding (Lap Band)

Roux-en Y Gastric bypass (RYGB) Sleeve Gastrectomy

MALABSORPTIVE- LIMITS DIGESTION AND ABSORPTION Decreases length of intestine exposed to digested food

25 of fat is absorbed Behavior modification

Biliopancreatic Diversion Duodenal Switch (BPDDS)

ALL OPERATIONS CAN BE PERFORMED OPEN OR LAPAROSCOPICALLY

Laparoscopic vs Open

OPEN uarr post op pain Longer hospitalizations uarr wound complications

Infection Hernias Seromas

Return to work in 4-8 weeks

LAPAROSCOPIC darr post op pain Early mobility darr Wound complications 2-3 day hospital stay Return to work in 1-3 weeks

1 Nguyen NT et al Accelerated growth of bariatric surgery with the introduction of minimally invasive surgery Arch Surg 20051401198-202

Procedures that are solely restrictive by creating a small gastric pouch of volume 15 to 30 cc amp a degree of outlet obstruction leading to delayed gastric emptying The goal is to reduce oral intake by limiting gastric volume produce early satiety and leave the alimentary canal in continuity minimizing the risks of metabolic complications

1VERTICAL BANDED GASTROPLASTY

2ADJUSTABLE GASTRIC BANDING (LAGB )

3 SLEEVE GASTRECTOMY

4GASTRIC PLICATION

5 INTRA GASTRIC BALLOON (GASTRIC BALLOON)

RESTRICTIVE PROCEDURES

Malabsorption is achieved by creating a short gut syndrome andor by accomplishing distal mixing of bile and pancreatic juice with ingested nutrients thereby reducing absorption Some purely malabsorptive operations are no longer recommended due to their potential hazard to cause serious nutritional deficiencies

1 BILIOPANCREATIC DIVERSION2 THE JEJUNAL-ILEAL BYPASS3 ENDOLUMINAL SLEEVE

MALABSORPTIVE PROCEDURES

MIXED PROCEDURES

1GASTRIC BYPASS ROUX-EN-Y ( RYGBP)

2SLEEVE GASTRECTOMY WITH DUODENAL SWITCH

3IMPLANTABLE 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

The stomach is partitioned along its axis with a non-

adjustable poly-urethane band and with linear amp 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 was practiced in 1980

Vertical Banded Gastroplasty (VBG)

ADJUSTABLE GASTRIC BANDING (LAP BAND SURGERY LAGB)

Restrictive Procedure The procedure was first performed by Cadiere in 1992 but was made popular by Belachew and Legrand in 1993 An inflatable silicone BAND is placed around the top portion of the stomach to form a small stomach pouch amp sewed

This band is connected to a tube that leads to a port above the abdominal muscles placed below the skin (FILL ndash PORT)

During follow up visits we inject or remove saline solution to make the band tighter or looser

Adjustable Gastric Band

bull 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

How does the Band work

Surgery Factors Restriction of meal size Decreased appetite

Patient Factors Decreased calorie intake Increased calorie expenditure

LAP-BAND Adjustability

Unfilled Band Filled Band

Adjustments are made in the office

Complications of Gastric Lap-Band

bull Perforation of Stomachbull Slippagebull Gastric Erosion(much less after Pars flaccida technique) bull Dilated Esophagusbull Tubing access port problemsbull Mal positioningbull Abdominal Painbull Heartburnbull Vomitingbull Inability to Adjust the Bandbull Failure to Lose Weightbull Infection of Systembull Fatigue or malfunction

Advantages

No intestinal surgery No staplingcutting of stomach No nutritional risks Adjustable Reversible Safe

Foreign body Frequent follow-up visits Needs more commitment Easy to cheat

Disadvantages

Comparison of Adjustable Gastric Banding and Vertical Banded Gastroplasty

Laparoscopic adjustable gastric banding Reversible Adjustable Simpler to perform laparoscopically Sustained weight loss of gt50 EBW gt5

years following surgery Complications Gastric prolapse band

erosion rarely gastric perforation and access port complications

Vertical banded gastroplasty Irreversible Non adjustable Technically difficult by laparoscopy Weight loss of 25-50 EBW and weight gain

after 2-3 years Complications suture line disruption gastric

leak weight gain

>

>

Originally used as the first-stage operation for a proposed biliopancreatic diversion with duodenal switch in high-risk patients

The sleeve gastrectomy has caught on as a primary obesity treatment as surgeons are reporting weight loss of 55 of excess body weight past 5 years in some patients

The sleeve gastrectomy is also known as the greater curvature gastrectomy vertical or longitudinal gastrectomy or Pylorus preserving lsquogastric tube creationrsquo

Rapid and less traumatic operation Good resolution of co-morbidities and good weight loss

A further second surgical step is then easily feasible if necessary

SLEEVE GASTRECTOMY

SLEEVE GASTRECTOMY

A sleeve gastrectomy involves resection of

approximately 80 of the greater curvature

side of the stomach

Smaller tubular gastric ldquosleeverdquo created

along the lesser curve that is based on the

lesser curvature blood supply

Ideal approximate capacity of the stomach

after the procedure is about 30- 60 ml pouch

1MECHANICAL RESTRICTION by reducing the volume of the stomach and impairing stomach mobility Also called lsquoFood limitingrsquo operation

2HORMONAL MODIFICATION by removing a great part of the Ghrelin (Hunger Hormone) production tissue

(Ghrelin is a 28 amino-acid-peptide secreted by the oxyntic glands of the gastric fungus It is a potent orexigenic (appetite-stimulating) peptide mediated by the activation of its receptors in the hypothalamus or pituitary area)

The gastric fundus contains 10 to 20 times more ghrelin per one gram of tissue than the duodenum In the SG resection of the fundus removes the major portion of ghrelin release therefore appetite decreases

The sleeve gastrectomy (SG) induces weight loss by 2 mechanisms

>

Intragastric balloon involves placing a deflated balloon into the stomach and then filling it to decrease the amount of gastric space

The balloon can be left in the stomach for a maximum of 6 months and results in an average weight loss of 5ndash9 BMI over half a year

Done endoscopically

The intragastric balloon may be used prior to another bariatric surgery as a step-down procedure

INTRA GASTRIC BALLOON

>

>

The EndoBarrier gastrointestinal liner mimics the effects of gastric bypass surgery

Itrsquos designed to work by inserting a flexible

tube-like barrier into the duodenum amp 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

ENDO BARRIER LINER SYSTEM

B MAL- ABSORPTIVE PROCEDURES

Malabsorptive surgeries rearrange andor remove part of digestive system which then limits the amount of calories and nutrients that body can absorb Treatment with a large malabsorptive component results in the most weight loss but tend to have slightly higher complication rates

1JEJUNAL ILEAL BYPASS ndash no longer performed for high complication rates

2ILEAL TRANSPOSITION- New malabsoptive procedure on trial for treatment of DM type 2 and metabolic disorders

C COMBINATION PROCEDURES RESTRICTIVE + MALABSORBTIVE

1LAP GASTRIC BYPASS ndash ROUX-EN- Y ndash more malabsorption than the restrictive

2MINI- GASTRIC BYPASS- mainly restrictive

3DUODENAL SWITCH ndash the sleeve stomach is the restrictive portion ampthe intestinal bypass (duodenal switch) is the malabsorptive component

When surgery combines both restrictive and malabsorptive techniques it is know as a ldquocombinationrdquo procedure Most types of bariatric surgery carry at least a small element of both components but the following surgeries achieve a notable portion of weight loss from eachhellip

1 LAP GASTRIC BYPASS LGB

The Roux-en-Y gastric bypass(known simply as the LRYGBP) is the most commonly performed procedure

It primarily causesweight loss by restricting thefood intake however there ismore amount of mal absorption that occurs with this operation

GASTRIC BYPASS LRYGBP

bullThe stomach is stapled into2 pieces one small and one large The small piece becomes the ldquonewrdquo stomach pouch

bull The larger portion of the stomach stays in place however will lie dormant for the remainder of the patientrsquos life

GASTRIC BYPASS LGB

bull The small intestine (the jejunum) is divided using a surgical staplerApprox 50-70 cm from the DJ Junction

GASTRIC BYPASS LGB

Y- LIMB BP LIMB

bull The end of the Roux limb is then attached to the newly formed stomach pouch which carries food to the distal intestine

bull The Roux loop is completed by forming a jejunostomy

bull The Y limb or BPD limb carries digestive juices from the pancreas gall bladder liver and duodenum to the intestines

bull The food and the digestive juices mix where the Roux limb and Y limb meet much below say 100-150 cm from DJ

Roux limb or alimentary limb

100-150 cm

How Does the Roux-en-Y Work

Surgery factors restriction of meal size ldquodumping syndromerdquo some malabsorption decreased appetite

Patient factors calorie intake calorie expenditure

bull Most commonly performedbull Most reliable operation for long term weight lossbull Long term weight loss averages 60 to 75 percent of EBWbull Malnutrition is unusualbull Substantial improvement amp resolution in many co-morbid

obesity conditions

ADVANTAGES OF RYGBP

1 Not reversible

2 Mortality 05- 1

3 Perioperative complications 5-10

4 Stricture of gastrojejunostomy-10 (long term)

5 Long term risk of protein amp vitamin deficiency and marginal ulceration of GJA

6Long term risk of intestinal obstruction ndash 2

LAPAROSCOPIC GASTRIC BYPASSCOMPLICATIONS

Biliopancreatic Diversion (BPD)

Primarily malabsorptive but restrictive component also

First Terminal ileum is measured to a length of 50 cms marked with suture

The alimentary tract beyond the proximal part of stomach is rearranged to

include only distal 200 cm of ileum including common channel

Common channel-Distal 50 cm of terminal ileum for absorption of fat and

protein

The proximal end of ileum anastomosed to proximal end of stomach after

performing distal hemigastrectomy

Biliopancreatic Diversion with Duodenal Switch

Modification to lessen high incidence of vit b12 deficiency anastomotic stricture at gastrojejunal anastomosis

This procedure involves a sleeve gastrectomy that is then diverted at the duodenum into the ileum at a point measured proximally from the ileocecal valve (usually 250 cm)

The distal duodenum and jejunum the biliopancreatic limb are then anastomosed to the ileum at a point measured proximally from the ileocecal valve (usually 100 cm)

Common channel is 100cm Entire alimentary tract is 250 cm This is the most aggressive bypass procedure commonly offered today Major difference-Sleeve gastrectomy instead of distal hemigastrectomy

bull Most women regained normal menstrual function and most had documented

spontaneous ovulation

bull Significant improvement in hirsutism androgen profiles and about a 50 reduction in

HOMA-IR

bull Follow up for more than 2 years showed that all women resumed normal menstrual

cycles HbA1C decreased from 82 to 51 in lt 3 months

bull 78 saw improvement in metabolic syndrome amp 48 showed improvement in PCOS

2 ROLE OF BARIATRIC SURGERY IN PCOS PATIENTS

bull Decrease menstrual irregularities bull PCOS women have less hyper androgenism

bull Sex hormone binding globulin increases bull LH and FSH levels have been reported to increase

bull Ovulatory function measured by luteal LH and Progesterone secretion improved bull Leptin levels decrease reflecting improved reproductive metabolic status

bull Subclinical hypothyroidism significantly reduced

THE SAFE TIMING OF PREGNANCYoptimal or minimal time gt12 months after bariatric surgery before becoming pregnant in order to allow the rapid weight loss and metabolic changes to subside

4 BARIATRIC SURGERY IN REPRODUCTIVE WOMEN

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)

The foregut hypothesis theory ndash 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

Effect of Bariatric Surgery on Diabetes Mellitus

Combined Gastric Restriction amp Malabsorption

Operative Risks (vs cholecystectomy)

Perioperative Mortality 1-2 vs 02-08 Early Complications 10 vs 29Late Complications 20 vs 1-2

LimitationsWidening of (unbanded) gastrojejunostomyExpansion of gastric pouch 25 with nearly 100 weight regainAdaptation of limb that receives the food

SUMMARY OF ALL TYPES OF SURGERY

bull LRYGBP ndash worlds best procedure 60-70 WL dumping syndrome malnutrition

bull LAGB- low complications varying range of wt loss frequent post-op visits ( 10)

bull DSBPD- more wt loss high complications good for high BMI gt 50 malabsorption +

bull VBG(vertical band gastroplasty) ndash longest available results good wt loss improved co-morbidities right for some ptsrisks too high to justify rewards

bull SG- needs long term research 1st step procedure low risks higher wt loss lesser complications pouch could Stretch over time long staple line could cause problems in future frequency is accelerating because of technical ease 1st stage procedure before bypass

Post-surgical Complications

Anastomosis leaks or staple line leaks Pulmonary Embolism or DVT Cholelithiasis Stomal ulceration Dumping syndrome Constipation

Anastamosis Leaks

Up to 7-10 days after surgery Most common at gastrojejunostomy enteroenterostomy Roux

limb stump staple line Can lead to peritonitis sepsis possible death Presentation

Tachycardia tachypnea Fever Ab painback pain Pelvic pressure or rebound tenderness

Anastamosis Leaks

Order Gastrograffin upper GI series Subclinical cases

Bowel rest Parenteral nutrition IV antibiotic if H pylori

Clinically suspect leak Laparoscopic evaluation and leak repair

Failure to evaluate is the most common cause of preventable major long-term disability or death in bariatric surgical patients

Pulmonary Embolism

Sudden cause of death up to one month after surgery 20-30 mortality rate High risk may have vena cava filter placement prior to surgery Prophylaxis with compression stockings and LMWH Early ambulation imperitive

Pulmonary Embolism

Presentation Profound hypoxia Hypotension Signs of sepsis

Immediate spiral chest CT Abdominal exploration if too large for machine No pathology start anticoagulation Too largehelliphellipNO SURGERY

Cholelithiasis

Up to 36 of patients within 6 months post-op Bile stasis leads to increased sludge and gallstones Prophylactic cholecystectomy prior to surgery if

evidence of existing sludge or stones Prevent post-operative disease with concurrent bariatric

surgery and cholecystectomy Prophylactic use of urosidol

Expensive and unpalatable

Stomal Ulceration

12-15 within 2-4 mos Post-surgery Etiology

Overabundant acid in pouch leads to excessive acid passing through stoma

Pouch tension and staple line breakdown NSAID use

Presentation Dyspepsia vomiting Epigastric or retrosternal pain

Stomal Ulceration

Treatment PPI carafate Antibiotics if H Pylori Avoid NSAIDS alcohol smoking

If no response to treatment Endoscopy Back to surgery for pouch revision or staple line repair

Dumping Syndrome

More than 15 patients Hypotention Tachycardia Lightheadedness syncope Flushing Abdominal cramping and diarrhea Nausea and vomiting

Dumping Syndrome

Occurs with high dose simple sugar ingestion Sugar in small intestine causes osmotic overload and fluid

shift from blood to intestine Increased intestinal volume leads to watery diarrhea Decreased blood volume leads to systemic changes Patient education

Eat slowly Avoid drinking before during and not until 30 minutes after meals

Constipation

Most common complaint Causes

Dehydration and decreased fluid intake post-operatively Increased metabolic water needs Calcium and iron supplement use following surgery

Treat with increased fluids and stool softeners

Nutritional Consequences

Iron deficiency anemia B12 deficiency Folate deficiency Calcium and Vitamin D deficiency

Not seen with purely restrictive surgeries

Iron deficiency and anemia

Common following RYGB As high as 49 of patients Multifactorial cause

Low gastric acid levels prohibit iron cleavage from food Absorption inhibited because no nutrient exposure to duodenum or

proximal jejunum Decrease in iron-rich food consumption due to intolerance

Treat with oral supplementation of ferrous sulfate or ferrous gluconate

Vitamin B12 deficiency

Up to 70 of patients Lack of hydrochloric acid and pepsin in stomach

Prevents B12 cleavage from food Affects secretion of intrinsic factor thus B12 absorption

Intolerance to meat and milk Oral supplementation usually adequate otherwise IM injections used

Folate Deficiency

40 of gastric bypass patients Complete absorption requires B12 Absorption dependent on HCl and upper 13 stomach Deficiency generally caused by decreased consumption Oral supplementation

Vitamin D and Calcium Deficiency

Vitamin D deficiency is common among obese people Calcium absorption decreased because duodenum is

bypassed Intolerance to dairy foods high in calcium Vitamin D is required for Ca++ absorption Prolonged deficiencies lead to

Bone resorption osteomalacia osteoporosis Treat with calcium citrate supplementation and 2 weekly

doses of Vitamin D

Nutritional Implications of Various Bariatric Surgeries(34)

bull RYGB Malabsorption of Vit B12 Vit B1 (thiamin) Vit D Vit K Folate Iron Calcium

bull LAGB Folic Acid deficiency

bull BPD and BPDDS Vit A D E and K deficiency Protein-Calorie Malnutrition Malabsorption of

Calcium Zinc Selenium Sodium Potassium Chloride Phosphorus Magnesium

Recommended Daily Supplements(4)

Multivitamin with iron (prenatal vitamin will have adeq amount of folic acid)

Calcium (citrate) with vitamin D (1200-1500 mg calcium with 800-1000 IU vitamin D)

Oral vitamin B12 (500-1000 mcg) Iron (65 mgday in elemental form)

Vitamin C (to increase absorption of Iron) Thiamin (10 mgday)

Diet Recommendations(3)

Reduce food volume Chew food very well Slow pace of eating No liquids with meals Encourage fruits and vegetables as diet progresses Include high protein foods (at least 60gday) may need protein

supplements

Diet Progression Gastric Bypass

Stage 1 Clear liquids and protein supplement (1 week)

Stage 2No concentrated sweets low fat puree diet ( 3 weeks)

Stage 3 Regular texture weight reduction diet

Diet Progression Lap - Band

Stage 1 Clear liquids and protein supplement ( 2 weeks)

Stage 2 No concentrated sweets low fat puree diet (2weeks)

Stage 3 Regular texture weight reduction diet

Stage 1

Only clear liquids allowed Avoid sweetened beverages Sip very slowly No straws Avoid caffeinated carbonated and alcoholic beverages STOP drinking if you feel fullness pain or discomfort

Protein supplements

Begin the day after you go home from Hospital

Minimum protein target 70gmsday

May use powder or pre-mixed liquid forms (Whey protein is preferred)

Protein pills may not be used

Vitamin and Mineral Supplements

Gastric bypass patients In addition to eating much less food gastric bypass patients will also

absorb vitamins and minerals differently after surgery They will require daily multivitamin calcium and iron

supplementation for the rest of your life

Vitamin and Mineral Supplements

Lap-Bandreg patients

Require a multivitamin with minerals daily

It may be necessary to take additional vitamins and minerals eg calcium iron folateB1 B12These will be prescribed as needed

Stage 2 dietPUREE

Puree diet

Regular scheduled meals Avoid meal skipping Plan meals in advance Eat Slowly Eat protein foods first Moisten meats Use liquid protein as supplement not as meal replacement

Measure 2 oz portions at each meal eating when full Separate liquids and solids No bread rice or pasta Avoid added sugars and high fat

foods VARIETY

The Toxic Environment

Etiology of Obesity

Debate is ongoing regarding the relative Genetic Vs Environmental components of the disease Clear familial predisposition Specific Genes Hundreds of genetic loci have been associated experimentally to obesity in the so-called

Human Obesity Gene Map

1) FTO-Fat mass and Obesity-related gene

2) MC4R-Melanocortin 4 receptor gene

Associated with obesity increased fat mass and insulin resistance Thrifty Gene Hypothesis During human development thrifty gene allowed for more efficient absorption

and use of the calories ingested However in modern society it helps increase the intake of calories in excess of metabolic needs

Role of genes versus environment

Pathophysiology Of Obesity

Obesity can result from increased energy intake decreased energy expenditure or a combination of the two

The severely obese individual has in general persistent hunger that is not satiated by amounts of food that satisfy the non-obese

This lack of satiety or maintenance of satiety may be the single most important factor in the process

Nutrient ingestion into the stomach or proximal intestine elicits hormonal signals that release neuropeptides which in turn alter body metabolism

Hormones Leptin and Ghrelin are appetite stimulant orexigenic Insulin and Cholecystokinin are anorexic

Obesity Related Co-Morbidities

Co-Morbidity Diabetes Hypertension Hyperlipidemia Cardiac disease Respiratory disease Obstructive sleep apnea Arthritis Depression Stress Incontinence Joint problems

Occurrence in the Obese 14ndash20 25ndash55 35ndash53 10ndash15

10ndash20 20ndash25 70ndash90 50 50

Pulmonary diseaseabnormal functionobstructive sleep apneahypoventilation syndrome

Nonalcoholic fatty liver diseasesteatosissteatohepatitiscirrhosis

Coronary heart disease Diabetes Dyslipidemia Hypertension

Gynecologic abnormalitiesabnormal mensesinfertilitypolycystic ovarian syndrome

Osteoarthritis

Skin

Gall bladder disease

Cancerbreast uterus cervixcolon esophagus pancreaskidney prostate

Phlebitisvenous stasis

Gout

Medical Complications of Obesity Idiopathic intracranial

hypertensionStroke

Cataracts

Severe pancreatitis

What are your optionsSource Adkinson Am J Clinical Nutrition 1994

1 Diet Exercise Behavioral Changes -up to 10 loss of excess body weight -ineffective long-term less than 5 sustain significant weight loss2 Weight Loss Drugs -minimal sustained weight loss -side effects prevent long-term use3 Weight-Loss Surgery -55 to 75 loss of excess body weight

Guidelines for the Treatment of Overweight and Obese Individuals

Indications for drug treatment

Pharmacological treatments are typically used as an adjunct to diet and exercise for patients with BMI of 30 or greater BMI of ge27 for patients with obesity-related risk factors or

comorbid diseases

Obesity Drugs Appetite suppressants

Noradrenergic (Schedule IV) Phentermine (Adipex Fastin) Diethylpropion (Tenuate)

Noradrenergic (Schedule III) Benzphetamine (Didrex) Phendimetrazine (Bontril)

Serotonergic Fenfluramine dexfenfluramine

Mixed Noradrenergic amp Serotonergic Sibutramine (Meridia)

Nutrient absorption reducers Lipase inhibitor

Orlistat (Xenical)

Sibutramine (Meridia)

Blocks presynaptic receptor uptake of norepinephrine and serotonin thereby potentiating their anorexic effect in the central nervous system

Contraindicated CAD CHF cardiac arrhythmias or stroke Side Effects hypertension arrhythmia tachycardia headache dry

mouth constipation insomnia

Orlistat

Inhibits pancreatic lipase and thereby reduces absorption of up to 30 of ingested dietary fat

Lipase inhibitor reduces fat absorption by ~30 resulting in reduction in energy intake

Inhibits digestion of dietary triglycerides decreases absorption of cholesterol and lipid-soluble vitamins

Side Effects

GI side effects due to inhibition of fat absorption pain fecal urgency liquid stools flatulence with discharge

oily spotting

Why Diets Often Fail

Require lot of time and energy

Cause feelings of deprivation

Donrsquot address why people overeat

Disrupt metabolism

Why SurgeryDiet and exercise are not effective

long term in the morbidly obese Surgery is an accepted and effective approach Medical co-morbidities are improvedresolved Increases life expectancy Decreases health care costs Surgical risk is acceptable vs risk of long-term obesity

RESOLUTION OF DISEASES FOLLOWING BARIATRIC SURGERY

Who Is a Surgical Candidate BMI gt 40 kgm2

-OR- BMI gt 35 kgm2 and major medical complications of

obesity-AND-

Failure of other approaches to long-term weight loss Age 18-55(relative)

Recommended BMI values for Bariatric Surgery in Asians

BMI ge 375

BMI ge 325 with two

associated co-

morbidities

No endocrine cause of obesity Acceptable operative risk Understands surgery and risks Absence of drug or alcohol problem No uncontrolled psychological conditions Consensus after bariatric team

evaluation SurgeonDieticianPsychologistConsultant

Dedicated to life-style change and follow-up

Obesity multidisciplinary team

Surgeon Physician Anesthetist Dietician Specialist bariatric nurse Skilled theatre staff Psychiatrist

Bariatric Surgery and Diabetes

International Diabetes Federation (2011) Journal of Diabetes (3(2011) 261-264) ldquoBariatric surgery is an appropriate treatment of people with T2D and

obesity who are not achieving recommended treatment targets with existing medical therapies especially in the presence of other major comorbiditiesrdquo

lt1 of those eligible actually have WLS for diabetes

Contraindications

Factors that may be considered contraindications include unstable CAD uncontrolled severe OSA uncontrolled psychiatric disorder mental retardation (IQ lt 60) inability to understand the surgery perceived inability to adhere to postoperative restrictions continued drug abuse malignancy with a poor 5-year survival prognosis Cirrhotic liver disease with portal hypertension

Preoperative EvaluationAttention should focus on issues unique to the obese patient

particularly cardiorespiratory status and the airwayConsideration of co morbidities ie hypertension diabetes heart

failure IHD obesity-hypoventilation syndrome metabolic syndrome etc

Results of the sleep study History of previous surgeries their anesthetic challenges need for

ICU admissionCurrent medicationsPatients scheduled for repeat bariatric surgery should be screened

preoperatively for long-term metabolic and nutritional abnormalities

Investigationshellip Recommended preoperative laboratory evaluations include

fasting blood glucose lipid profile electrolytes serum chemistries (to evaluate renal and hepatic function) complete blood count Serum ferritin vitamin B12 thyrotropin amp 25-hydroxyvitamin D

(Miller 7th edition- anesthesia for Bariatic Surgery) ABG measurements help evaluate ventilation as well as the need for perioperative oxygen administration and

postoperative ventilation Routine pulmonary function tests and liver function tests are not cost-effective in asymptomatic obese patients Coaugulation profile ( liver problem repeat surgery orlistat) ECG echocardiography Sleep study if suspected OSA

(Barash 6th edition anesthesia and obesity)

Concurrent Preoperative and Prophylactic Medications

Patients usual medications should be continued until the time of surgery with the possible exception of insulin and oral hypoglycemics

Antibiotic prophylaxis is usually indicated

Obesity itself does not increase the risk for aspiration acid aspiration prophylaxis including H2 receptor agonists or proton pump inhibitors must be considered in patients with identifiable risk for aspiration

Anxiolysis and prophylaxis against deep vein thrombosis (DVT) should be addressed at premedication

DVT consideration Morbid obesity is a major independent risk factor for sudden death from

acute postoperative pulmonary embolism Subcutaneous heparin 5000 IU administered before surgery and repeated every 8 to 12

hours until the patient is fully mobile reduces the risk of DVT LMWH can also be used

Preoperative prophylactic placement of an inferior vena cava filter should be considered in venous stasis disease BMI ge60 truncal obesity and OSA

What Are the Risks

MAJOR RISKS Death (1 of patients die within 30 days) Severe malnutrition (anemia PEM osteomalacia) Peritonitis (from leakage or ruptures at staple sites)

or other infection Obstructions caused by scar tissue in the stomach or

bowels

MINOR RISKS Dumping Syndrome (unpleasant but not harmful) Diarrhea and malodorous gas production Lactose intolerance Hair loss (short-term post-surgery) May have to eventually undergo surgical revision Pain post-surgery

History of Bariatric Surgery

Obesity surgery is not a new discipline The earliest Bariatric procedure performed was in 1954 at Minnesota The procedure

was Jejuno-ileal bypass In 1966Gastric Bypass was introduced as a surgical procedure for weight loss at the

University of Iowa In 1977Griffen reported the first Roux-en-Y Gastric Bypass In 1980surgeons with a more conservative approach developed the Vertical Banded

Gastroplasty Other procedures with longer intestinal segment bypass were also introduced such as

Biliopancreatic Diversions These complex procedures are recommended in super-obese patients ie BMIgt60

How does surgery work

RESTRICTIVE - RESTRICT AMOUNT OF FOOD INGESTED Decreases appetitehunger

Early satiety Behavior modification Gastric Banding (Lap Band)

Roux-en Y Gastric bypass (RYGB) Sleeve Gastrectomy

MALABSORPTIVE- LIMITS DIGESTION AND ABSORPTION Decreases length of intestine exposed to digested food

25 of fat is absorbed Behavior modification

Biliopancreatic Diversion Duodenal Switch (BPDDS)

ALL OPERATIONS CAN BE PERFORMED OPEN OR LAPAROSCOPICALLY

Laparoscopic vs Open

OPEN uarr post op pain Longer hospitalizations uarr wound complications

Infection Hernias Seromas

Return to work in 4-8 weeks

LAPAROSCOPIC darr post op pain Early mobility darr Wound complications 2-3 day hospital stay Return to work in 1-3 weeks

1 Nguyen NT et al Accelerated growth of bariatric surgery with the introduction of minimally invasive surgery Arch Surg 20051401198-202

Procedures that are solely restrictive by creating a small gastric pouch of volume 15 to 30 cc amp a degree of outlet obstruction leading to delayed gastric emptying The goal is to reduce oral intake by limiting gastric volume produce early satiety and leave the alimentary canal in continuity minimizing the risks of metabolic complications

1VERTICAL BANDED GASTROPLASTY

2ADJUSTABLE GASTRIC BANDING (LAGB )

3 SLEEVE GASTRECTOMY

4GASTRIC PLICATION

5 INTRA GASTRIC BALLOON (GASTRIC BALLOON)

RESTRICTIVE PROCEDURES

Malabsorption is achieved by creating a short gut syndrome andor by accomplishing distal mixing of bile and pancreatic juice with ingested nutrients thereby reducing absorption Some purely malabsorptive operations are no longer recommended due to their potential hazard to cause serious nutritional deficiencies

1 BILIOPANCREATIC DIVERSION2 THE JEJUNAL-ILEAL BYPASS3 ENDOLUMINAL SLEEVE

MALABSORPTIVE PROCEDURES

MIXED PROCEDURES

1GASTRIC BYPASS ROUX-EN-Y ( RYGBP)

2SLEEVE GASTRECTOMY WITH DUODENAL SWITCH

3IMPLANTABLE 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

The stomach is partitioned along its axis with a non-

adjustable poly-urethane band and with linear amp 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 was practiced in 1980

Vertical Banded Gastroplasty (VBG)

ADJUSTABLE GASTRIC BANDING (LAP BAND SURGERY LAGB)

Restrictive Procedure The procedure was first performed by Cadiere in 1992 but was made popular by Belachew and Legrand in 1993 An inflatable silicone BAND is placed around the top portion of the stomach to form a small stomach pouch amp sewed

This band is connected to a tube that leads to a port above the abdominal muscles placed below the skin (FILL ndash PORT)

During follow up visits we inject or remove saline solution to make the band tighter or looser

Adjustable Gastric Band

bull 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

How does the Band work

Surgery Factors Restriction of meal size Decreased appetite

Patient Factors Decreased calorie intake Increased calorie expenditure

LAP-BAND Adjustability

Unfilled Band Filled Band

Adjustments are made in the office

Complications of Gastric Lap-Band

bull Perforation of Stomachbull Slippagebull Gastric Erosion(much less after Pars flaccida technique) bull Dilated Esophagusbull Tubing access port problemsbull Mal positioningbull Abdominal Painbull Heartburnbull Vomitingbull Inability to Adjust the Bandbull Failure to Lose Weightbull Infection of Systembull Fatigue or malfunction

Advantages

No intestinal surgery No staplingcutting of stomach No nutritional risks Adjustable Reversible Safe

Foreign body Frequent follow-up visits Needs more commitment Easy to cheat

Disadvantages

Comparison of Adjustable Gastric Banding and Vertical Banded Gastroplasty

Laparoscopic adjustable gastric banding Reversible Adjustable Simpler to perform laparoscopically Sustained weight loss of gt50 EBW gt5

years following surgery Complications Gastric prolapse band

erosion rarely gastric perforation and access port complications

Vertical banded gastroplasty Irreversible Non adjustable Technically difficult by laparoscopy Weight loss of 25-50 EBW and weight gain

after 2-3 years Complications suture line disruption gastric

leak weight gain

>

>

Originally used as the first-stage operation for a proposed biliopancreatic diversion with duodenal switch in high-risk patients

The sleeve gastrectomy has caught on as a primary obesity treatment as surgeons are reporting weight loss of 55 of excess body weight past 5 years in some patients

The sleeve gastrectomy is also known as the greater curvature gastrectomy vertical or longitudinal gastrectomy or Pylorus preserving lsquogastric tube creationrsquo

Rapid and less traumatic operation Good resolution of co-morbidities and good weight loss

A further second surgical step is then easily feasible if necessary

SLEEVE GASTRECTOMY

SLEEVE GASTRECTOMY

A sleeve gastrectomy involves resection of

approximately 80 of the greater curvature

side of the stomach

Smaller tubular gastric ldquosleeverdquo created

along the lesser curve that is based on the

lesser curvature blood supply

Ideal approximate capacity of the stomach

after the procedure is about 30- 60 ml pouch

1MECHANICAL RESTRICTION by reducing the volume of the stomach and impairing stomach mobility Also called lsquoFood limitingrsquo operation

2HORMONAL MODIFICATION by removing a great part of the Ghrelin (Hunger Hormone) production tissue

(Ghrelin is a 28 amino-acid-peptide secreted by the oxyntic glands of the gastric fungus It is a potent orexigenic (appetite-stimulating) peptide mediated by the activation of its receptors in the hypothalamus or pituitary area)

The gastric fundus contains 10 to 20 times more ghrelin per one gram of tissue than the duodenum In the SG resection of the fundus removes the major portion of ghrelin release therefore appetite decreases

The sleeve gastrectomy (SG) induces weight loss by 2 mechanisms

>

Intragastric balloon involves placing a deflated balloon into the stomach and then filling it to decrease the amount of gastric space

The balloon can be left in the stomach for a maximum of 6 months and results in an average weight loss of 5ndash9 BMI over half a year

Done endoscopically

The intragastric balloon may be used prior to another bariatric surgery as a step-down procedure

INTRA GASTRIC BALLOON

>

>

The EndoBarrier gastrointestinal liner mimics the effects of gastric bypass surgery

Itrsquos designed to work by inserting a flexible

tube-like barrier into the duodenum amp 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

ENDO BARRIER LINER SYSTEM

B MAL- ABSORPTIVE PROCEDURES

Malabsorptive surgeries rearrange andor remove part of digestive system which then limits the amount of calories and nutrients that body can absorb Treatment with a large malabsorptive component results in the most weight loss but tend to have slightly higher complication rates

1JEJUNAL ILEAL BYPASS ndash no longer performed for high complication rates

2ILEAL TRANSPOSITION- New malabsoptive procedure on trial for treatment of DM type 2 and metabolic disorders

C COMBINATION PROCEDURES RESTRICTIVE + MALABSORBTIVE

1LAP GASTRIC BYPASS ndash ROUX-EN- Y ndash more malabsorption than the restrictive

2MINI- GASTRIC BYPASS- mainly restrictive

3DUODENAL SWITCH ndash the sleeve stomach is the restrictive portion ampthe intestinal bypass (duodenal switch) is the malabsorptive component

When surgery combines both restrictive and malabsorptive techniques it is know as a ldquocombinationrdquo procedure Most types of bariatric surgery carry at least a small element of both components but the following surgeries achieve a notable portion of weight loss from eachhellip

1 LAP GASTRIC BYPASS LGB

The Roux-en-Y gastric bypass(known simply as the LRYGBP) is the most commonly performed procedure

It primarily causesweight loss by restricting thefood intake however there ismore amount of mal absorption that occurs with this operation

GASTRIC BYPASS LRYGBP

bullThe stomach is stapled into2 pieces one small and one large The small piece becomes the ldquonewrdquo stomach pouch

bull The larger portion of the stomach stays in place however will lie dormant for the remainder of the patientrsquos life

GASTRIC BYPASS LGB

bull The small intestine (the jejunum) is divided using a surgical staplerApprox 50-70 cm from the DJ Junction

GASTRIC BYPASS LGB

Y- LIMB BP LIMB

bull The end of the Roux limb is then attached to the newly formed stomach pouch which carries food to the distal intestine

bull The Roux loop is completed by forming a jejunostomy

bull The Y limb or BPD limb carries digestive juices from the pancreas gall bladder liver and duodenum to the intestines

bull The food and the digestive juices mix where the Roux limb and Y limb meet much below say 100-150 cm from DJ

Roux limb or alimentary limb

100-150 cm

How Does the Roux-en-Y Work

Surgery factors restriction of meal size ldquodumping syndromerdquo some malabsorption decreased appetite

Patient factors calorie intake calorie expenditure

bull Most commonly performedbull Most reliable operation for long term weight lossbull Long term weight loss averages 60 to 75 percent of EBWbull Malnutrition is unusualbull Substantial improvement amp resolution in many co-morbid

obesity conditions

ADVANTAGES OF RYGBP

1 Not reversible

2 Mortality 05- 1

3 Perioperative complications 5-10

4 Stricture of gastrojejunostomy-10 (long term)

5 Long term risk of protein amp vitamin deficiency and marginal ulceration of GJA

6Long term risk of intestinal obstruction ndash 2

LAPAROSCOPIC GASTRIC BYPASSCOMPLICATIONS

Biliopancreatic Diversion (BPD)

Primarily malabsorptive but restrictive component also

First Terminal ileum is measured to a length of 50 cms marked with suture

The alimentary tract beyond the proximal part of stomach is rearranged to

include only distal 200 cm of ileum including common channel

Common channel-Distal 50 cm of terminal ileum for absorption of fat and

protein

The proximal end of ileum anastomosed to proximal end of stomach after

performing distal hemigastrectomy

Biliopancreatic Diversion with Duodenal Switch

Modification to lessen high incidence of vit b12 deficiency anastomotic stricture at gastrojejunal anastomosis

This procedure involves a sleeve gastrectomy that is then diverted at the duodenum into the ileum at a point measured proximally from the ileocecal valve (usually 250 cm)

The distal duodenum and jejunum the biliopancreatic limb are then anastomosed to the ileum at a point measured proximally from the ileocecal valve (usually 100 cm)

Common channel is 100cm Entire alimentary tract is 250 cm This is the most aggressive bypass procedure commonly offered today Major difference-Sleeve gastrectomy instead of distal hemigastrectomy

bull Most women regained normal menstrual function and most had documented

spontaneous ovulation

bull Significant improvement in hirsutism androgen profiles and about a 50 reduction in

HOMA-IR

bull Follow up for more than 2 years showed that all women resumed normal menstrual

cycles HbA1C decreased from 82 to 51 in lt 3 months

bull 78 saw improvement in metabolic syndrome amp 48 showed improvement in PCOS

2 ROLE OF BARIATRIC SURGERY IN PCOS PATIENTS

bull Decrease menstrual irregularities bull PCOS women have less hyper androgenism

bull Sex hormone binding globulin increases bull LH and FSH levels have been reported to increase

bull Ovulatory function measured by luteal LH and Progesterone secretion improved bull Leptin levels decrease reflecting improved reproductive metabolic status

bull Subclinical hypothyroidism significantly reduced

THE SAFE TIMING OF PREGNANCYoptimal or minimal time gt12 months after bariatric surgery before becoming pregnant in order to allow the rapid weight loss and metabolic changes to subside

4 BARIATRIC SURGERY IN REPRODUCTIVE WOMEN

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)

The foregut hypothesis theory ndash 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

Effect of Bariatric Surgery on Diabetes Mellitus

Combined Gastric Restriction amp Malabsorption

Operative Risks (vs cholecystectomy)

Perioperative Mortality 1-2 vs 02-08 Early Complications 10 vs 29Late Complications 20 vs 1-2

LimitationsWidening of (unbanded) gastrojejunostomyExpansion of gastric pouch 25 with nearly 100 weight regainAdaptation of limb that receives the food

SUMMARY OF ALL TYPES OF SURGERY

bull LRYGBP ndash worlds best procedure 60-70 WL dumping syndrome malnutrition

bull LAGB- low complications varying range of wt loss frequent post-op visits ( 10)

bull DSBPD- more wt loss high complications good for high BMI gt 50 malabsorption +

bull VBG(vertical band gastroplasty) ndash longest available results good wt loss improved co-morbidities right for some ptsrisks too high to justify rewards

bull SG- needs long term research 1st step procedure low risks higher wt loss lesser complications pouch could Stretch over time long staple line could cause problems in future frequency is accelerating because of technical ease 1st stage procedure before bypass

Post-surgical Complications

Anastomosis leaks or staple line leaks Pulmonary Embolism or DVT Cholelithiasis Stomal ulceration Dumping syndrome Constipation

Anastamosis Leaks

Up to 7-10 days after surgery Most common at gastrojejunostomy enteroenterostomy Roux

limb stump staple line Can lead to peritonitis sepsis possible death Presentation

Tachycardia tachypnea Fever Ab painback pain Pelvic pressure or rebound tenderness

Anastamosis Leaks

Order Gastrograffin upper GI series Subclinical cases

Bowel rest Parenteral nutrition IV antibiotic if H pylori

Clinically suspect leak Laparoscopic evaluation and leak repair

Failure to evaluate is the most common cause of preventable major long-term disability or death in bariatric surgical patients

Pulmonary Embolism

Sudden cause of death up to one month after surgery 20-30 mortality rate High risk may have vena cava filter placement prior to surgery Prophylaxis with compression stockings and LMWH Early ambulation imperitive

Pulmonary Embolism

Presentation Profound hypoxia Hypotension Signs of sepsis

Immediate spiral chest CT Abdominal exploration if too large for machine No pathology start anticoagulation Too largehelliphellipNO SURGERY

Cholelithiasis

Up to 36 of patients within 6 months post-op Bile stasis leads to increased sludge and gallstones Prophylactic cholecystectomy prior to surgery if

evidence of existing sludge or stones Prevent post-operative disease with concurrent bariatric

surgery and cholecystectomy Prophylactic use of urosidol

Expensive and unpalatable

Stomal Ulceration

12-15 within 2-4 mos Post-surgery Etiology

Overabundant acid in pouch leads to excessive acid passing through stoma

Pouch tension and staple line breakdown NSAID use

Presentation Dyspepsia vomiting Epigastric or retrosternal pain

Stomal Ulceration

Treatment PPI carafate Antibiotics if H Pylori Avoid NSAIDS alcohol smoking

If no response to treatment Endoscopy Back to surgery for pouch revision or staple line repair

Dumping Syndrome

More than 15 patients Hypotention Tachycardia Lightheadedness syncope Flushing Abdominal cramping and diarrhea Nausea and vomiting

Dumping Syndrome

Occurs with high dose simple sugar ingestion Sugar in small intestine causes osmotic overload and fluid

shift from blood to intestine Increased intestinal volume leads to watery diarrhea Decreased blood volume leads to systemic changes Patient education

Eat slowly Avoid drinking before during and not until 30 minutes after meals

Constipation

Most common complaint Causes

Dehydration and decreased fluid intake post-operatively Increased metabolic water needs Calcium and iron supplement use following surgery

Treat with increased fluids and stool softeners

Nutritional Consequences

Iron deficiency anemia B12 deficiency Folate deficiency Calcium and Vitamin D deficiency

Not seen with purely restrictive surgeries

Iron deficiency and anemia

Common following RYGB As high as 49 of patients Multifactorial cause

Low gastric acid levels prohibit iron cleavage from food Absorption inhibited because no nutrient exposure to duodenum or

proximal jejunum Decrease in iron-rich food consumption due to intolerance

Treat with oral supplementation of ferrous sulfate or ferrous gluconate

Vitamin B12 deficiency

Up to 70 of patients Lack of hydrochloric acid and pepsin in stomach

Prevents B12 cleavage from food Affects secretion of intrinsic factor thus B12 absorption

Intolerance to meat and milk Oral supplementation usually adequate otherwise IM injections used

Folate Deficiency

40 of gastric bypass patients Complete absorption requires B12 Absorption dependent on HCl and upper 13 stomach Deficiency generally caused by decreased consumption Oral supplementation

Vitamin D and Calcium Deficiency

Vitamin D deficiency is common among obese people Calcium absorption decreased because duodenum is

bypassed Intolerance to dairy foods high in calcium Vitamin D is required for Ca++ absorption Prolonged deficiencies lead to

Bone resorption osteomalacia osteoporosis Treat with calcium citrate supplementation and 2 weekly

doses of Vitamin D

Nutritional Implications of Various Bariatric Surgeries(34)

bull RYGB Malabsorption of Vit B12 Vit B1 (thiamin) Vit D Vit K Folate Iron Calcium

bull LAGB Folic Acid deficiency

bull BPD and BPDDS Vit A D E and K deficiency Protein-Calorie Malnutrition Malabsorption of

Calcium Zinc Selenium Sodium Potassium Chloride Phosphorus Magnesium

Recommended Daily Supplements(4)

Multivitamin with iron (prenatal vitamin will have adeq amount of folic acid)

Calcium (citrate) with vitamin D (1200-1500 mg calcium with 800-1000 IU vitamin D)

Oral vitamin B12 (500-1000 mcg) Iron (65 mgday in elemental form)

Vitamin C (to increase absorption of Iron) Thiamin (10 mgday)

Diet Recommendations(3)

Reduce food volume Chew food very well Slow pace of eating No liquids with meals Encourage fruits and vegetables as diet progresses Include high protein foods (at least 60gday) may need protein

supplements

Diet Progression Gastric Bypass

Stage 1 Clear liquids and protein supplement (1 week)

Stage 2No concentrated sweets low fat puree diet ( 3 weeks)

Stage 3 Regular texture weight reduction diet

Diet Progression Lap - Band

Stage 1 Clear liquids and protein supplement ( 2 weeks)

Stage 2 No concentrated sweets low fat puree diet (2weeks)

Stage 3 Regular texture weight reduction diet

Stage 1

Only clear liquids allowed Avoid sweetened beverages Sip very slowly No straws Avoid caffeinated carbonated and alcoholic beverages STOP drinking if you feel fullness pain or discomfort

Protein supplements

Begin the day after you go home from Hospital

Minimum protein target 70gmsday

May use powder or pre-mixed liquid forms (Whey protein is preferred)

Protein pills may not be used

Vitamin and Mineral Supplements

Gastric bypass patients In addition to eating much less food gastric bypass patients will also

absorb vitamins and minerals differently after surgery They will require daily multivitamin calcium and iron

supplementation for the rest of your life

Vitamin and Mineral Supplements

Lap-Bandreg patients

Require a multivitamin with minerals daily

It may be necessary to take additional vitamins and minerals eg calcium iron folateB1 B12These will be prescribed as needed

Stage 2 dietPUREE

Puree diet

Regular scheduled meals Avoid meal skipping Plan meals in advance Eat Slowly Eat protein foods first Moisten meats Use liquid protein as supplement not as meal replacement

Measure 2 oz portions at each meal eating when full Separate liquids and solids No bread rice or pasta Avoid added sugars and high fat

foods VARIETY

Etiology of Obesity

Debate is ongoing regarding the relative Genetic Vs Environmental components of the disease Clear familial predisposition Specific Genes Hundreds of genetic loci have been associated experimentally to obesity in the so-called

Human Obesity Gene Map

1) FTO-Fat mass and Obesity-related gene

2) MC4R-Melanocortin 4 receptor gene

Associated with obesity increased fat mass and insulin resistance Thrifty Gene Hypothesis During human development thrifty gene allowed for more efficient absorption

and use of the calories ingested However in modern society it helps increase the intake of calories in excess of metabolic needs

Role of genes versus environment

Pathophysiology Of Obesity

Obesity can result from increased energy intake decreased energy expenditure or a combination of the two

The severely obese individual has in general persistent hunger that is not satiated by amounts of food that satisfy the non-obese

This lack of satiety or maintenance of satiety may be the single most important factor in the process

Nutrient ingestion into the stomach or proximal intestine elicits hormonal signals that release neuropeptides which in turn alter body metabolism

Hormones Leptin and Ghrelin are appetite stimulant orexigenic Insulin and Cholecystokinin are anorexic

Obesity Related Co-Morbidities

Co-Morbidity Diabetes Hypertension Hyperlipidemia Cardiac disease Respiratory disease Obstructive sleep apnea Arthritis Depression Stress Incontinence Joint problems

Occurrence in the Obese 14ndash20 25ndash55 35ndash53 10ndash15

10ndash20 20ndash25 70ndash90 50 50

Pulmonary diseaseabnormal functionobstructive sleep apneahypoventilation syndrome

Nonalcoholic fatty liver diseasesteatosissteatohepatitiscirrhosis

Coronary heart disease Diabetes Dyslipidemia Hypertension

Gynecologic abnormalitiesabnormal mensesinfertilitypolycystic ovarian syndrome

Osteoarthritis

Skin

Gall bladder disease

Cancerbreast uterus cervixcolon esophagus pancreaskidney prostate

Phlebitisvenous stasis

Gout

Medical Complications of Obesity Idiopathic intracranial

hypertensionStroke

Cataracts

Severe pancreatitis

What are your optionsSource Adkinson Am J Clinical Nutrition 1994

1 Diet Exercise Behavioral Changes -up to 10 loss of excess body weight -ineffective long-term less than 5 sustain significant weight loss2 Weight Loss Drugs -minimal sustained weight loss -side effects prevent long-term use3 Weight-Loss Surgery -55 to 75 loss of excess body weight

Guidelines for the Treatment of Overweight and Obese Individuals

Indications for drug treatment

Pharmacological treatments are typically used as an adjunct to diet and exercise for patients with BMI of 30 or greater BMI of ge27 for patients with obesity-related risk factors or

comorbid diseases

Obesity Drugs Appetite suppressants

Noradrenergic (Schedule IV) Phentermine (Adipex Fastin) Diethylpropion (Tenuate)

Noradrenergic (Schedule III) Benzphetamine (Didrex) Phendimetrazine (Bontril)

Serotonergic Fenfluramine dexfenfluramine

Mixed Noradrenergic amp Serotonergic Sibutramine (Meridia)

Nutrient absorption reducers Lipase inhibitor

Orlistat (Xenical)

Sibutramine (Meridia)

Blocks presynaptic receptor uptake of norepinephrine and serotonin thereby potentiating their anorexic effect in the central nervous system

Contraindicated CAD CHF cardiac arrhythmias or stroke Side Effects hypertension arrhythmia tachycardia headache dry

mouth constipation insomnia

Orlistat

Inhibits pancreatic lipase and thereby reduces absorption of up to 30 of ingested dietary fat

Lipase inhibitor reduces fat absorption by ~30 resulting in reduction in energy intake

Inhibits digestion of dietary triglycerides decreases absorption of cholesterol and lipid-soluble vitamins

Side Effects

GI side effects due to inhibition of fat absorption pain fecal urgency liquid stools flatulence with discharge

oily spotting

Why Diets Often Fail

Require lot of time and energy

Cause feelings of deprivation

Donrsquot address why people overeat

Disrupt metabolism

Why SurgeryDiet and exercise are not effective

long term in the morbidly obese Surgery is an accepted and effective approach Medical co-morbidities are improvedresolved Increases life expectancy Decreases health care costs Surgical risk is acceptable vs risk of long-term obesity

RESOLUTION OF DISEASES FOLLOWING BARIATRIC SURGERY

Who Is a Surgical Candidate BMI gt 40 kgm2

-OR- BMI gt 35 kgm2 and major medical complications of

obesity-AND-

Failure of other approaches to long-term weight loss Age 18-55(relative)

Recommended BMI values for Bariatric Surgery in Asians

BMI ge 375

BMI ge 325 with two

associated co-

morbidities

No endocrine cause of obesity Acceptable operative risk Understands surgery and risks Absence of drug or alcohol problem No uncontrolled psychological conditions Consensus after bariatric team

evaluation SurgeonDieticianPsychologistConsultant

Dedicated to life-style change and follow-up

Obesity multidisciplinary team

Surgeon Physician Anesthetist Dietician Specialist bariatric nurse Skilled theatre staff Psychiatrist

Bariatric Surgery and Diabetes

International Diabetes Federation (2011) Journal of Diabetes (3(2011) 261-264) ldquoBariatric surgery is an appropriate treatment of people with T2D and

obesity who are not achieving recommended treatment targets with existing medical therapies especially in the presence of other major comorbiditiesrdquo

lt1 of those eligible actually have WLS for diabetes

Contraindications

Factors that may be considered contraindications include unstable CAD uncontrolled severe OSA uncontrolled psychiatric disorder mental retardation (IQ lt 60) inability to understand the surgery perceived inability to adhere to postoperative restrictions continued drug abuse malignancy with a poor 5-year survival prognosis Cirrhotic liver disease with portal hypertension

Preoperative EvaluationAttention should focus on issues unique to the obese patient

particularly cardiorespiratory status and the airwayConsideration of co morbidities ie hypertension diabetes heart

failure IHD obesity-hypoventilation syndrome metabolic syndrome etc

Results of the sleep study History of previous surgeries their anesthetic challenges need for

ICU admissionCurrent medicationsPatients scheduled for repeat bariatric surgery should be screened

preoperatively for long-term metabolic and nutritional abnormalities

Investigationshellip Recommended preoperative laboratory evaluations include

fasting blood glucose lipid profile electrolytes serum chemistries (to evaluate renal and hepatic function) complete blood count Serum ferritin vitamin B12 thyrotropin amp 25-hydroxyvitamin D

(Miller 7th edition- anesthesia for Bariatic Surgery) ABG measurements help evaluate ventilation as well as the need for perioperative oxygen administration and

postoperative ventilation Routine pulmonary function tests and liver function tests are not cost-effective in asymptomatic obese patients Coaugulation profile ( liver problem repeat surgery orlistat) ECG echocardiography Sleep study if suspected OSA

(Barash 6th edition anesthesia and obesity)

Concurrent Preoperative and Prophylactic Medications

Patients usual medications should be continued until the time of surgery with the possible exception of insulin and oral hypoglycemics

Antibiotic prophylaxis is usually indicated

Obesity itself does not increase the risk for aspiration acid aspiration prophylaxis including H2 receptor agonists or proton pump inhibitors must be considered in patients with identifiable risk for aspiration

Anxiolysis and prophylaxis against deep vein thrombosis (DVT) should be addressed at premedication

DVT consideration Morbid obesity is a major independent risk factor for sudden death from

acute postoperative pulmonary embolism Subcutaneous heparin 5000 IU administered before surgery and repeated every 8 to 12

hours until the patient is fully mobile reduces the risk of DVT LMWH can also be used

Preoperative prophylactic placement of an inferior vena cava filter should be considered in venous stasis disease BMI ge60 truncal obesity and OSA

What Are the Risks

MAJOR RISKS Death (1 of patients die within 30 days) Severe malnutrition (anemia PEM osteomalacia) Peritonitis (from leakage or ruptures at staple sites)

or other infection Obstructions caused by scar tissue in the stomach or

bowels

MINOR RISKS Dumping Syndrome (unpleasant but not harmful) Diarrhea and malodorous gas production Lactose intolerance Hair loss (short-term post-surgery) May have to eventually undergo surgical revision Pain post-surgery

History of Bariatric Surgery

Obesity surgery is not a new discipline The earliest Bariatric procedure performed was in 1954 at Minnesota The procedure

was Jejuno-ileal bypass In 1966Gastric Bypass was introduced as a surgical procedure for weight loss at the

University of Iowa In 1977Griffen reported the first Roux-en-Y Gastric Bypass In 1980surgeons with a more conservative approach developed the Vertical Banded

Gastroplasty Other procedures with longer intestinal segment bypass were also introduced such as

Biliopancreatic Diversions These complex procedures are recommended in super-obese patients ie BMIgt60

How does surgery work

RESTRICTIVE - RESTRICT AMOUNT OF FOOD INGESTED Decreases appetitehunger

Early satiety Behavior modification Gastric Banding (Lap Band)

Roux-en Y Gastric bypass (RYGB) Sleeve Gastrectomy

MALABSORPTIVE- LIMITS DIGESTION AND ABSORPTION Decreases length of intestine exposed to digested food

25 of fat is absorbed Behavior modification

Biliopancreatic Diversion Duodenal Switch (BPDDS)

ALL OPERATIONS CAN BE PERFORMED OPEN OR LAPAROSCOPICALLY

Laparoscopic vs Open

OPEN uarr post op pain Longer hospitalizations uarr wound complications

Infection Hernias Seromas

Return to work in 4-8 weeks

LAPAROSCOPIC darr post op pain Early mobility darr Wound complications 2-3 day hospital stay Return to work in 1-3 weeks

1 Nguyen NT et al Accelerated growth of bariatric surgery with the introduction of minimally invasive surgery Arch Surg 20051401198-202

Procedures that are solely restrictive by creating a small gastric pouch of volume 15 to 30 cc amp a degree of outlet obstruction leading to delayed gastric emptying The goal is to reduce oral intake by limiting gastric volume produce early satiety and leave the alimentary canal in continuity minimizing the risks of metabolic complications

1VERTICAL BANDED GASTROPLASTY

2ADJUSTABLE GASTRIC BANDING (LAGB )

3 SLEEVE GASTRECTOMY

4GASTRIC PLICATION

5 INTRA GASTRIC BALLOON (GASTRIC BALLOON)

RESTRICTIVE PROCEDURES

Malabsorption is achieved by creating a short gut syndrome andor by accomplishing distal mixing of bile and pancreatic juice with ingested nutrients thereby reducing absorption Some purely malabsorptive operations are no longer recommended due to their potential hazard to cause serious nutritional deficiencies

1 BILIOPANCREATIC DIVERSION2 THE JEJUNAL-ILEAL BYPASS3 ENDOLUMINAL SLEEVE

MALABSORPTIVE PROCEDURES

MIXED PROCEDURES

1GASTRIC BYPASS ROUX-EN-Y ( RYGBP)

2SLEEVE GASTRECTOMY WITH DUODENAL SWITCH

3IMPLANTABLE 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

The stomach is partitioned along its axis with a non-

adjustable poly-urethane band and with linear amp 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 was practiced in 1980

Vertical Banded Gastroplasty (VBG)

ADJUSTABLE GASTRIC BANDING (LAP BAND SURGERY LAGB)

Restrictive Procedure The procedure was first performed by Cadiere in 1992 but was made popular by Belachew and Legrand in 1993 An inflatable silicone BAND is placed around the top portion of the stomach to form a small stomach pouch amp sewed

This band is connected to a tube that leads to a port above the abdominal muscles placed below the skin (FILL ndash PORT)

During follow up visits we inject or remove saline solution to make the band tighter or looser

Adjustable Gastric Band

bull 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

How does the Band work

Surgery Factors Restriction of meal size Decreased appetite

Patient Factors Decreased calorie intake Increased calorie expenditure

LAP-BAND Adjustability

Unfilled Band Filled Band

Adjustments are made in the office

Complications of Gastric Lap-Band

bull Perforation of Stomachbull Slippagebull Gastric Erosion(much less after Pars flaccida technique) bull Dilated Esophagusbull Tubing access port problemsbull Mal positioningbull Abdominal Painbull Heartburnbull Vomitingbull Inability to Adjust the Bandbull Failure to Lose Weightbull Infection of Systembull Fatigue or malfunction

Advantages

No intestinal surgery No staplingcutting of stomach No nutritional risks Adjustable Reversible Safe

Foreign body Frequent follow-up visits Needs more commitment Easy to cheat

Disadvantages

Comparison of Adjustable Gastric Banding and Vertical Banded Gastroplasty

Laparoscopic adjustable gastric banding Reversible Adjustable Simpler to perform laparoscopically Sustained weight loss of gt50 EBW gt5

years following surgery Complications Gastric prolapse band

erosion rarely gastric perforation and access port complications

Vertical banded gastroplasty Irreversible Non adjustable Technically difficult by laparoscopy Weight loss of 25-50 EBW and weight gain

after 2-3 years Complications suture line disruption gastric

leak weight gain

>

>

Originally used as the first-stage operation for a proposed biliopancreatic diversion with duodenal switch in high-risk patients

The sleeve gastrectomy has caught on as a primary obesity treatment as surgeons are reporting weight loss of 55 of excess body weight past 5 years in some patients

The sleeve gastrectomy is also known as the greater curvature gastrectomy vertical or longitudinal gastrectomy or Pylorus preserving lsquogastric tube creationrsquo

Rapid and less traumatic operation Good resolution of co-morbidities and good weight loss

A further second surgical step is then easily feasible if necessary

SLEEVE GASTRECTOMY

SLEEVE GASTRECTOMY

A sleeve gastrectomy involves resection of

approximately 80 of the greater curvature

side of the stomach

Smaller tubular gastric ldquosleeverdquo created

along the lesser curve that is based on the

lesser curvature blood supply

Ideal approximate capacity of the stomach

after the procedure is about 30- 60 ml pouch

1MECHANICAL RESTRICTION by reducing the volume of the stomach and impairing stomach mobility Also called lsquoFood limitingrsquo operation

2HORMONAL MODIFICATION by removing a great part of the Ghrelin (Hunger Hormone) production tissue

(Ghrelin is a 28 amino-acid-peptide secreted by the oxyntic glands of the gastric fungus It is a potent orexigenic (appetite-stimulating) peptide mediated by the activation of its receptors in the hypothalamus or pituitary area)

The gastric fundus contains 10 to 20 times more ghrelin per one gram of tissue than the duodenum In the SG resection of the fundus removes the major portion of ghrelin release therefore appetite decreases

The sleeve gastrectomy (SG) induces weight loss by 2 mechanisms

>

Intragastric balloon involves placing a deflated balloon into the stomach and then filling it to decrease the amount of gastric space

The balloon can be left in the stomach for a maximum of 6 months and results in an average weight loss of 5ndash9 BMI over half a year

Done endoscopically

The intragastric balloon may be used prior to another bariatric surgery as a step-down procedure

INTRA GASTRIC BALLOON

>

>

The EndoBarrier gastrointestinal liner mimics the effects of gastric bypass surgery

Itrsquos designed to work by inserting a flexible

tube-like barrier into the duodenum amp 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

ENDO BARRIER LINER SYSTEM

B MAL- ABSORPTIVE PROCEDURES

Malabsorptive surgeries rearrange andor remove part of digestive system which then limits the amount of calories and nutrients that body can absorb Treatment with a large malabsorptive component results in the most weight loss but tend to have slightly higher complication rates

1JEJUNAL ILEAL BYPASS ndash no longer performed for high complication rates

2ILEAL TRANSPOSITION- New malabsoptive procedure on trial for treatment of DM type 2 and metabolic disorders

C COMBINATION PROCEDURES RESTRICTIVE + MALABSORBTIVE

1LAP GASTRIC BYPASS ndash ROUX-EN- Y ndash more malabsorption than the restrictive

2MINI- GASTRIC BYPASS- mainly restrictive

3DUODENAL SWITCH ndash the sleeve stomach is the restrictive portion ampthe intestinal bypass (duodenal switch) is the malabsorptive component

When surgery combines both restrictive and malabsorptive techniques it is know as a ldquocombinationrdquo procedure Most types of bariatric surgery carry at least a small element of both components but the following surgeries achieve a notable portion of weight loss from eachhellip

1 LAP GASTRIC BYPASS LGB

The Roux-en-Y gastric bypass(known simply as the LRYGBP) is the most commonly performed procedure

It primarily causesweight loss by restricting thefood intake however there ismore amount of mal absorption that occurs with this operation

GASTRIC BYPASS LRYGBP

bullThe stomach is stapled into2 pieces one small and one large The small piece becomes the ldquonewrdquo stomach pouch

bull The larger portion of the stomach stays in place however will lie dormant for the remainder of the patientrsquos life

GASTRIC BYPASS LGB

bull The small intestine (the jejunum) is divided using a surgical staplerApprox 50-70 cm from the DJ Junction

GASTRIC BYPASS LGB

Y- LIMB BP LIMB

bull The end of the Roux limb is then attached to the newly formed stomach pouch which carries food to the distal intestine

bull The Roux loop is completed by forming a jejunostomy

bull The Y limb or BPD limb carries digestive juices from the pancreas gall bladder liver and duodenum to the intestines

bull The food and the digestive juices mix where the Roux limb and Y limb meet much below say 100-150 cm from DJ

Roux limb or alimentary limb

100-150 cm

How Does the Roux-en-Y Work

Surgery factors restriction of meal size ldquodumping syndromerdquo some malabsorption decreased appetite

Patient factors calorie intake calorie expenditure

bull Most commonly performedbull Most reliable operation for long term weight lossbull Long term weight loss averages 60 to 75 percent of EBWbull Malnutrition is unusualbull Substantial improvement amp resolution in many co-morbid

obesity conditions

ADVANTAGES OF RYGBP

1 Not reversible

2 Mortality 05- 1

3 Perioperative complications 5-10

4 Stricture of gastrojejunostomy-10 (long term)

5 Long term risk of protein amp vitamin deficiency and marginal ulceration of GJA

6Long term risk of intestinal obstruction ndash 2

LAPAROSCOPIC GASTRIC BYPASSCOMPLICATIONS

Biliopancreatic Diversion (BPD)

Primarily malabsorptive but restrictive component also

First Terminal ileum is measured to a length of 50 cms marked with suture

The alimentary tract beyond the proximal part of stomach is rearranged to

include only distal 200 cm of ileum including common channel

Common channel-Distal 50 cm of terminal ileum for absorption of fat and

protein

The proximal end of ileum anastomosed to proximal end of stomach after

performing distal hemigastrectomy

Biliopancreatic Diversion with Duodenal Switch

Modification to lessen high incidence of vit b12 deficiency anastomotic stricture at gastrojejunal anastomosis

This procedure involves a sleeve gastrectomy that is then diverted at the duodenum into the ileum at a point measured proximally from the ileocecal valve (usually 250 cm)

The distal duodenum and jejunum the biliopancreatic limb are then anastomosed to the ileum at a point measured proximally from the ileocecal valve (usually 100 cm)

Common channel is 100cm Entire alimentary tract is 250 cm This is the most aggressive bypass procedure commonly offered today Major difference-Sleeve gastrectomy instead of distal hemigastrectomy

bull Most women regained normal menstrual function and most had documented

spontaneous ovulation

bull Significant improvement in hirsutism androgen profiles and about a 50 reduction in

HOMA-IR

bull Follow up for more than 2 years showed that all women resumed normal menstrual

cycles HbA1C decreased from 82 to 51 in lt 3 months

bull 78 saw improvement in metabolic syndrome amp 48 showed improvement in PCOS

2 ROLE OF BARIATRIC SURGERY IN PCOS PATIENTS

bull Decrease menstrual irregularities bull PCOS women have less hyper androgenism

bull Sex hormone binding globulin increases bull LH and FSH levels have been reported to increase

bull Ovulatory function measured by luteal LH and Progesterone secretion improved bull Leptin levels decrease reflecting improved reproductive metabolic status

bull Subclinical hypothyroidism significantly reduced

THE SAFE TIMING OF PREGNANCYoptimal or minimal time gt12 months after bariatric surgery before becoming pregnant in order to allow the rapid weight loss and metabolic changes to subside

4 BARIATRIC SURGERY IN REPRODUCTIVE WOMEN

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)

The foregut hypothesis theory ndash 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

Effect of Bariatric Surgery on Diabetes Mellitus

Combined Gastric Restriction amp Malabsorption

Operative Risks (vs cholecystectomy)

Perioperative Mortality 1-2 vs 02-08 Early Complications 10 vs 29Late Complications 20 vs 1-2

LimitationsWidening of (unbanded) gastrojejunostomyExpansion of gastric pouch 25 with nearly 100 weight regainAdaptation of limb that receives the food

SUMMARY OF ALL TYPES OF SURGERY

bull LRYGBP ndash worlds best procedure 60-70 WL dumping syndrome malnutrition

bull LAGB- low complications varying range of wt loss frequent post-op visits ( 10)

bull DSBPD- more wt loss high complications good for high BMI gt 50 malabsorption +

bull VBG(vertical band gastroplasty) ndash longest available results good wt loss improved co-morbidities right for some ptsrisks too high to justify rewards

bull SG- needs long term research 1st step procedure low risks higher wt loss lesser complications pouch could Stretch over time long staple line could cause problems in future frequency is accelerating because of technical ease 1st stage procedure before bypass

Post-surgical Complications

Anastomosis leaks or staple line leaks Pulmonary Embolism or DVT Cholelithiasis Stomal ulceration Dumping syndrome Constipation

Anastamosis Leaks

Up to 7-10 days after surgery Most common at gastrojejunostomy enteroenterostomy Roux

limb stump staple line Can lead to peritonitis sepsis possible death Presentation

Tachycardia tachypnea Fever Ab painback pain Pelvic pressure or rebound tenderness

Anastamosis Leaks

Order Gastrograffin upper GI series Subclinical cases

Bowel rest Parenteral nutrition IV antibiotic if H pylori

Clinically suspect leak Laparoscopic evaluation and leak repair

Failure to evaluate is the most common cause of preventable major long-term disability or death in bariatric surgical patients

Pulmonary Embolism

Sudden cause of death up to one month after surgery 20-30 mortality rate High risk may have vena cava filter placement prior to surgery Prophylaxis with compression stockings and LMWH Early ambulation imperitive

Pulmonary Embolism

Presentation Profound hypoxia Hypotension Signs of sepsis

Immediate spiral chest CT Abdominal exploration if too large for machine No pathology start anticoagulation Too largehelliphellipNO SURGERY

Cholelithiasis

Up to 36 of patients within 6 months post-op Bile stasis leads to increased sludge and gallstones Prophylactic cholecystectomy prior to surgery if

evidence of existing sludge or stones Prevent post-operative disease with concurrent bariatric

surgery and cholecystectomy Prophylactic use of urosidol

Expensive and unpalatable

Stomal Ulceration

12-15 within 2-4 mos Post-surgery Etiology

Overabundant acid in pouch leads to excessive acid passing through stoma

Pouch tension and staple line breakdown NSAID use

Presentation Dyspepsia vomiting Epigastric or retrosternal pain

Stomal Ulceration

Treatment PPI carafate Antibiotics if H Pylori Avoid NSAIDS alcohol smoking

If no response to treatment Endoscopy Back to surgery for pouch revision or staple line repair

Dumping Syndrome

More than 15 patients Hypotention Tachycardia Lightheadedness syncope Flushing Abdominal cramping and diarrhea Nausea and vomiting

Dumping Syndrome

Occurs with high dose simple sugar ingestion Sugar in small intestine causes osmotic overload and fluid

shift from blood to intestine Increased intestinal volume leads to watery diarrhea Decreased blood volume leads to systemic changes Patient education

Eat slowly Avoid drinking before during and not until 30 minutes after meals

Constipation

Most common complaint Causes

Dehydration and decreased fluid intake post-operatively Increased metabolic water needs Calcium and iron supplement use following surgery

Treat with increased fluids and stool softeners

Nutritional Consequences

Iron deficiency anemia B12 deficiency Folate deficiency Calcium and Vitamin D deficiency

Not seen with purely restrictive surgeries

Iron deficiency and anemia

Common following RYGB As high as 49 of patients Multifactorial cause

Low gastric acid levels prohibit iron cleavage from food Absorption inhibited because no nutrient exposure to duodenum or

proximal jejunum Decrease in iron-rich food consumption due to intolerance

Treat with oral supplementation of ferrous sulfate or ferrous gluconate

Vitamin B12 deficiency

Up to 70 of patients Lack of hydrochloric acid and pepsin in stomach

Prevents B12 cleavage from food Affects secretion of intrinsic factor thus B12 absorption

Intolerance to meat and milk Oral supplementation usually adequate otherwise IM injections used

Folate Deficiency

40 of gastric bypass patients Complete absorption requires B12 Absorption dependent on HCl and upper 13 stomach Deficiency generally caused by decreased consumption Oral supplementation

Vitamin D and Calcium Deficiency

Vitamin D deficiency is common among obese people Calcium absorption decreased because duodenum is

bypassed Intolerance to dairy foods high in calcium Vitamin D is required for Ca++ absorption Prolonged deficiencies lead to

Bone resorption osteomalacia osteoporosis Treat with calcium citrate supplementation and 2 weekly

doses of Vitamin D

Nutritional Implications of Various Bariatric Surgeries(34)

bull RYGB Malabsorption of Vit B12 Vit B1 (thiamin) Vit D Vit K Folate Iron Calcium

bull LAGB Folic Acid deficiency

bull BPD and BPDDS Vit A D E and K deficiency Protein-Calorie Malnutrition Malabsorption of

Calcium Zinc Selenium Sodium Potassium Chloride Phosphorus Magnesium

Recommended Daily Supplements(4)

Multivitamin with iron (prenatal vitamin will have adeq amount of folic acid)

Calcium (citrate) with vitamin D (1200-1500 mg calcium with 800-1000 IU vitamin D)

Oral vitamin B12 (500-1000 mcg) Iron (65 mgday in elemental form)

Vitamin C (to increase absorption of Iron) Thiamin (10 mgday)

Diet Recommendations(3)

Reduce food volume Chew food very well Slow pace of eating No liquids with meals Encourage fruits and vegetables as diet progresses Include high protein foods (at least 60gday) may need protein

supplements

Diet Progression Gastric Bypass

Stage 1 Clear liquids and protein supplement (1 week)

Stage 2No concentrated sweets low fat puree diet ( 3 weeks)

Stage 3 Regular texture weight reduction diet

Diet Progression Lap - Band

Stage 1 Clear liquids and protein supplement ( 2 weeks)

Stage 2 No concentrated sweets low fat puree diet (2weeks)

Stage 3 Regular texture weight reduction diet

Stage 1

Only clear liquids allowed Avoid sweetened beverages Sip very slowly No straws Avoid caffeinated carbonated and alcoholic beverages STOP drinking if you feel fullness pain or discomfort

Protein supplements

Begin the day after you go home from Hospital

Minimum protein target 70gmsday

May use powder or pre-mixed liquid forms (Whey protein is preferred)

Protein pills may not be used

Vitamin and Mineral Supplements

Gastric bypass patients In addition to eating much less food gastric bypass patients will also

absorb vitamins and minerals differently after surgery They will require daily multivitamin calcium and iron

supplementation for the rest of your life

Vitamin and Mineral Supplements

Lap-Bandreg patients

Require a multivitamin with minerals daily

It may be necessary to take additional vitamins and minerals eg calcium iron folateB1 B12These will be prescribed as needed

Stage 2 dietPUREE

Puree diet

Regular scheduled meals Avoid meal skipping Plan meals in advance Eat Slowly Eat protein foods first Moisten meats Use liquid protein as supplement not as meal replacement

Measure 2 oz portions at each meal eating when full Separate liquids and solids No bread rice or pasta Avoid added sugars and high fat

foods VARIETY

Pathophysiology Of Obesity

Obesity can result from increased energy intake decreased energy expenditure or a combination of the two

The severely obese individual has in general persistent hunger that is not satiated by amounts of food that satisfy the non-obese

This lack of satiety or maintenance of satiety may be the single most important factor in the process

Nutrient ingestion into the stomach or proximal intestine elicits hormonal signals that release neuropeptides which in turn alter body metabolism

Hormones Leptin and Ghrelin are appetite stimulant orexigenic Insulin and Cholecystokinin are anorexic

Obesity Related Co-Morbidities

Co-Morbidity Diabetes Hypertension Hyperlipidemia Cardiac disease Respiratory disease Obstructive sleep apnea Arthritis Depression Stress Incontinence Joint problems

Occurrence in the Obese 14ndash20 25ndash55 35ndash53 10ndash15

10ndash20 20ndash25 70ndash90 50 50

Pulmonary diseaseabnormal functionobstructive sleep apneahypoventilation syndrome

Nonalcoholic fatty liver diseasesteatosissteatohepatitiscirrhosis

Coronary heart disease Diabetes Dyslipidemia Hypertension

Gynecologic abnormalitiesabnormal mensesinfertilitypolycystic ovarian syndrome

Osteoarthritis

Skin

Gall bladder disease

Cancerbreast uterus cervixcolon esophagus pancreaskidney prostate

Phlebitisvenous stasis

Gout

Medical Complications of Obesity Idiopathic intracranial

hypertensionStroke

Cataracts

Severe pancreatitis

What are your optionsSource Adkinson Am J Clinical Nutrition 1994

1 Diet Exercise Behavioral Changes -up to 10 loss of excess body weight -ineffective long-term less than 5 sustain significant weight loss2 Weight Loss Drugs -minimal sustained weight loss -side effects prevent long-term use3 Weight-Loss Surgery -55 to 75 loss of excess body weight

Guidelines for the Treatment of Overweight and Obese Individuals

Indications for drug treatment

Pharmacological treatments are typically used as an adjunct to diet and exercise for patients with BMI of 30 or greater BMI of ge27 for patients with obesity-related risk factors or

comorbid diseases

Obesity Drugs Appetite suppressants

Noradrenergic (Schedule IV) Phentermine (Adipex Fastin) Diethylpropion (Tenuate)

Noradrenergic (Schedule III) Benzphetamine (Didrex) Phendimetrazine (Bontril)

Serotonergic Fenfluramine dexfenfluramine

Mixed Noradrenergic amp Serotonergic Sibutramine (Meridia)

Nutrient absorption reducers Lipase inhibitor

Orlistat (Xenical)

Sibutramine (Meridia)

Blocks presynaptic receptor uptake of norepinephrine and serotonin thereby potentiating their anorexic effect in the central nervous system

Contraindicated CAD CHF cardiac arrhythmias or stroke Side Effects hypertension arrhythmia tachycardia headache dry

mouth constipation insomnia

Orlistat

Inhibits pancreatic lipase and thereby reduces absorption of up to 30 of ingested dietary fat

Lipase inhibitor reduces fat absorption by ~30 resulting in reduction in energy intake

Inhibits digestion of dietary triglycerides decreases absorption of cholesterol and lipid-soluble vitamins

Side Effects

GI side effects due to inhibition of fat absorption pain fecal urgency liquid stools flatulence with discharge

oily spotting

Why Diets Often Fail

Require lot of time and energy

Cause feelings of deprivation

Donrsquot address why people overeat

Disrupt metabolism

Why SurgeryDiet and exercise are not effective

long term in the morbidly obese Surgery is an accepted and effective approach Medical co-morbidities are improvedresolved Increases life expectancy Decreases health care costs Surgical risk is acceptable vs risk of long-term obesity

RESOLUTION OF DISEASES FOLLOWING BARIATRIC SURGERY

Who Is a Surgical Candidate BMI gt 40 kgm2

-OR- BMI gt 35 kgm2 and major medical complications of

obesity-AND-

Failure of other approaches to long-term weight loss Age 18-55(relative)

Recommended BMI values for Bariatric Surgery in Asians

BMI ge 375

BMI ge 325 with two

associated co-

morbidities

No endocrine cause of obesity Acceptable operative risk Understands surgery and risks Absence of drug or alcohol problem No uncontrolled psychological conditions Consensus after bariatric team

evaluation SurgeonDieticianPsychologistConsultant

Dedicated to life-style change and follow-up

Obesity multidisciplinary team

Surgeon Physician Anesthetist Dietician Specialist bariatric nurse Skilled theatre staff Psychiatrist

Bariatric Surgery and Diabetes

International Diabetes Federation (2011) Journal of Diabetes (3(2011) 261-264) ldquoBariatric surgery is an appropriate treatment of people with T2D and

obesity who are not achieving recommended treatment targets with existing medical therapies especially in the presence of other major comorbiditiesrdquo

lt1 of those eligible actually have WLS for diabetes

Contraindications

Factors that may be considered contraindications include unstable CAD uncontrolled severe OSA uncontrolled psychiatric disorder mental retardation (IQ lt 60) inability to understand the surgery perceived inability to adhere to postoperative restrictions continued drug abuse malignancy with a poor 5-year survival prognosis Cirrhotic liver disease with portal hypertension

Preoperative EvaluationAttention should focus on issues unique to the obese patient

particularly cardiorespiratory status and the airwayConsideration of co morbidities ie hypertension diabetes heart

failure IHD obesity-hypoventilation syndrome metabolic syndrome etc

Results of the sleep study History of previous surgeries their anesthetic challenges need for

ICU admissionCurrent medicationsPatients scheduled for repeat bariatric surgery should be screened

preoperatively for long-term metabolic and nutritional abnormalities

Investigationshellip Recommended preoperative laboratory evaluations include

fasting blood glucose lipid profile electrolytes serum chemistries (to evaluate renal and hepatic function) complete blood count Serum ferritin vitamin B12 thyrotropin amp 25-hydroxyvitamin D

(Miller 7th edition- anesthesia for Bariatic Surgery) ABG measurements help evaluate ventilation as well as the need for perioperative oxygen administration and

postoperative ventilation Routine pulmonary function tests and liver function tests are not cost-effective in asymptomatic obese patients Coaugulation profile ( liver problem repeat surgery orlistat) ECG echocardiography Sleep study if suspected OSA

(Barash 6th edition anesthesia and obesity)

Concurrent Preoperative and Prophylactic Medications

Patients usual medications should be continued until the time of surgery with the possible exception of insulin and oral hypoglycemics

Antibiotic prophylaxis is usually indicated

Obesity itself does not increase the risk for aspiration acid aspiration prophylaxis including H2 receptor agonists or proton pump inhibitors must be considered in patients with identifiable risk for aspiration

Anxiolysis and prophylaxis against deep vein thrombosis (DVT) should be addressed at premedication

DVT consideration Morbid obesity is a major independent risk factor for sudden death from

acute postoperative pulmonary embolism Subcutaneous heparin 5000 IU administered before surgery and repeated every 8 to 12

hours until the patient is fully mobile reduces the risk of DVT LMWH can also be used

Preoperative prophylactic placement of an inferior vena cava filter should be considered in venous stasis disease BMI ge60 truncal obesity and OSA

What Are the Risks

MAJOR RISKS Death (1 of patients die within 30 days) Severe malnutrition (anemia PEM osteomalacia) Peritonitis (from leakage or ruptures at staple sites)

or other infection Obstructions caused by scar tissue in the stomach or

bowels

MINOR RISKS Dumping Syndrome (unpleasant but not harmful) Diarrhea and malodorous gas production Lactose intolerance Hair loss (short-term post-surgery) May have to eventually undergo surgical revision Pain post-surgery

History of Bariatric Surgery

Obesity surgery is not a new discipline The earliest Bariatric procedure performed was in 1954 at Minnesota The procedure

was Jejuno-ileal bypass In 1966Gastric Bypass was introduced as a surgical procedure for weight loss at the

University of Iowa In 1977Griffen reported the first Roux-en-Y Gastric Bypass In 1980surgeons with a more conservative approach developed the Vertical Banded

Gastroplasty Other procedures with longer intestinal segment bypass were also introduced such as

Biliopancreatic Diversions These complex procedures are recommended in super-obese patients ie BMIgt60

How does surgery work

RESTRICTIVE - RESTRICT AMOUNT OF FOOD INGESTED Decreases appetitehunger

Early satiety Behavior modification Gastric Banding (Lap Band)

Roux-en Y Gastric bypass (RYGB) Sleeve Gastrectomy

MALABSORPTIVE- LIMITS DIGESTION AND ABSORPTION Decreases length of intestine exposed to digested food

25 of fat is absorbed Behavior modification

Biliopancreatic Diversion Duodenal Switch (BPDDS)

ALL OPERATIONS CAN BE PERFORMED OPEN OR LAPAROSCOPICALLY

Laparoscopic vs Open

OPEN uarr post op pain Longer hospitalizations uarr wound complications

Infection Hernias Seromas

Return to work in 4-8 weeks

LAPAROSCOPIC darr post op pain Early mobility darr Wound complications 2-3 day hospital stay Return to work in 1-3 weeks

1 Nguyen NT et al Accelerated growth of bariatric surgery with the introduction of minimally invasive surgery Arch Surg 20051401198-202

Procedures that are solely restrictive by creating a small gastric pouch of volume 15 to 30 cc amp a degree of outlet obstruction leading to delayed gastric emptying The goal is to reduce oral intake by limiting gastric volume produce early satiety and leave the alimentary canal in continuity minimizing the risks of metabolic complications

1VERTICAL BANDED GASTROPLASTY

2ADJUSTABLE GASTRIC BANDING (LAGB )

3 SLEEVE GASTRECTOMY

4GASTRIC PLICATION

5 INTRA GASTRIC BALLOON (GASTRIC BALLOON)

RESTRICTIVE PROCEDURES

Malabsorption is achieved by creating a short gut syndrome andor by accomplishing distal mixing of bile and pancreatic juice with ingested nutrients thereby reducing absorption Some purely malabsorptive operations are no longer recommended due to their potential hazard to cause serious nutritional deficiencies

1 BILIOPANCREATIC DIVERSION2 THE JEJUNAL-ILEAL BYPASS3 ENDOLUMINAL SLEEVE

MALABSORPTIVE PROCEDURES

MIXED PROCEDURES

1GASTRIC BYPASS ROUX-EN-Y ( RYGBP)

2SLEEVE GASTRECTOMY WITH DUODENAL SWITCH

3IMPLANTABLE 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

The stomach is partitioned along its axis with a non-

adjustable poly-urethane band and with linear amp 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 was practiced in 1980

Vertical Banded Gastroplasty (VBG)

ADJUSTABLE GASTRIC BANDING (LAP BAND SURGERY LAGB)

Restrictive Procedure The procedure was first performed by Cadiere in 1992 but was made popular by Belachew and Legrand in 1993 An inflatable silicone BAND is placed around the top portion of the stomach to form a small stomach pouch amp sewed

This band is connected to a tube that leads to a port above the abdominal muscles placed below the skin (FILL ndash PORT)

During follow up visits we inject or remove saline solution to make the band tighter or looser

Adjustable Gastric Band

bull 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

How does the Band work

Surgery Factors Restriction of meal size Decreased appetite

Patient Factors Decreased calorie intake Increased calorie expenditure

LAP-BAND Adjustability

Unfilled Band Filled Band

Adjustments are made in the office

Complications of Gastric Lap-Band

bull Perforation of Stomachbull Slippagebull Gastric Erosion(much less after Pars flaccida technique) bull Dilated Esophagusbull Tubing access port problemsbull Mal positioningbull Abdominal Painbull Heartburnbull Vomitingbull Inability to Adjust the Bandbull Failure to Lose Weightbull Infection of Systembull Fatigue or malfunction

Advantages

No intestinal surgery No staplingcutting of stomach No nutritional risks Adjustable Reversible Safe

Foreign body Frequent follow-up visits Needs more commitment Easy to cheat

Disadvantages

Comparison of Adjustable Gastric Banding and Vertical Banded Gastroplasty

Laparoscopic adjustable gastric banding Reversible Adjustable Simpler to perform laparoscopically Sustained weight loss of gt50 EBW gt5

years following surgery Complications Gastric prolapse band

erosion rarely gastric perforation and access port complications

Vertical banded gastroplasty Irreversible Non adjustable Technically difficult by laparoscopy Weight loss of 25-50 EBW and weight gain

after 2-3 years Complications suture line disruption gastric

leak weight gain

>

>

Originally used as the first-stage operation for a proposed biliopancreatic diversion with duodenal switch in high-risk patients

The sleeve gastrectomy has caught on as a primary obesity treatment as surgeons are reporting weight loss of 55 of excess body weight past 5 years in some patients

The sleeve gastrectomy is also known as the greater curvature gastrectomy vertical or longitudinal gastrectomy or Pylorus preserving lsquogastric tube creationrsquo

Rapid and less traumatic operation Good resolution of co-morbidities and good weight loss

A further second surgical step is then easily feasible if necessary

SLEEVE GASTRECTOMY

SLEEVE GASTRECTOMY

A sleeve gastrectomy involves resection of

approximately 80 of the greater curvature

side of the stomach

Smaller tubular gastric ldquosleeverdquo created

along the lesser curve that is based on the

lesser curvature blood supply

Ideal approximate capacity of the stomach

after the procedure is about 30- 60 ml pouch

1MECHANICAL RESTRICTION by reducing the volume of the stomach and impairing stomach mobility Also called lsquoFood limitingrsquo operation

2HORMONAL MODIFICATION by removing a great part of the Ghrelin (Hunger Hormone) production tissue

(Ghrelin is a 28 amino-acid-peptide secreted by the oxyntic glands of the gastric fungus It is a potent orexigenic (appetite-stimulating) peptide mediated by the activation of its receptors in the hypothalamus or pituitary area)

The gastric fundus contains 10 to 20 times more ghrelin per one gram of tissue than the duodenum In the SG resection of the fundus removes the major portion of ghrelin release therefore appetite decreases

The sleeve gastrectomy (SG) induces weight loss by 2 mechanisms

>

Intragastric balloon involves placing a deflated balloon into the stomach and then filling it to decrease the amount of gastric space

The balloon can be left in the stomach for a maximum of 6 months and results in an average weight loss of 5ndash9 BMI over half a year

Done endoscopically

The intragastric balloon may be used prior to another bariatric surgery as a step-down procedure

INTRA GASTRIC BALLOON

>

>

The EndoBarrier gastrointestinal liner mimics the effects of gastric bypass surgery

Itrsquos designed to work by inserting a flexible

tube-like barrier into the duodenum amp 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

ENDO BARRIER LINER SYSTEM

B MAL- ABSORPTIVE PROCEDURES

Malabsorptive surgeries rearrange andor remove part of digestive system which then limits the amount of calories and nutrients that body can absorb Treatment with a large malabsorptive component results in the most weight loss but tend to have slightly higher complication rates

1JEJUNAL ILEAL BYPASS ndash no longer performed for high complication rates

2ILEAL TRANSPOSITION- New malabsoptive procedure on trial for treatment of DM type 2 and metabolic disorders

C COMBINATION PROCEDURES RESTRICTIVE + MALABSORBTIVE

1LAP GASTRIC BYPASS ndash ROUX-EN- Y ndash more malabsorption than the restrictive

2MINI- GASTRIC BYPASS- mainly restrictive

3DUODENAL SWITCH ndash the sleeve stomach is the restrictive portion ampthe intestinal bypass (duodenal switch) is the malabsorptive component

When surgery combines both restrictive and malabsorptive techniques it is know as a ldquocombinationrdquo procedure Most types of bariatric surgery carry at least a small element of both components but the following surgeries achieve a notable portion of weight loss from eachhellip

1 LAP GASTRIC BYPASS LGB

The Roux-en-Y gastric bypass(known simply as the LRYGBP) is the most commonly performed procedure

It primarily causesweight loss by restricting thefood intake however there ismore amount of mal absorption that occurs with this operation

GASTRIC BYPASS LRYGBP

bullThe stomach is stapled into2 pieces one small and one large The small piece becomes the ldquonewrdquo stomach pouch

bull The larger portion of the stomach stays in place however will lie dormant for the remainder of the patientrsquos life

GASTRIC BYPASS LGB

bull The small intestine (the jejunum) is divided using a surgical staplerApprox 50-70 cm from the DJ Junction

GASTRIC BYPASS LGB

Y- LIMB BP LIMB

bull The end of the Roux limb is then attached to the newly formed stomach pouch which carries food to the distal intestine

bull The Roux loop is completed by forming a jejunostomy

bull The Y limb or BPD limb carries digestive juices from the pancreas gall bladder liver and duodenum to the intestines

bull The food and the digestive juices mix where the Roux limb and Y limb meet much below say 100-150 cm from DJ

Roux limb or alimentary limb

100-150 cm

How Does the Roux-en-Y Work

Surgery factors restriction of meal size ldquodumping syndromerdquo some malabsorption decreased appetite

Patient factors calorie intake calorie expenditure

bull Most commonly performedbull Most reliable operation for long term weight lossbull Long term weight loss averages 60 to 75 percent of EBWbull Malnutrition is unusualbull Substantial improvement amp resolution in many co-morbid

obesity conditions

ADVANTAGES OF RYGBP

1 Not reversible

2 Mortality 05- 1

3 Perioperative complications 5-10

4 Stricture of gastrojejunostomy-10 (long term)

5 Long term risk of protein amp vitamin deficiency and marginal ulceration of GJA

6Long term risk of intestinal obstruction ndash 2

LAPAROSCOPIC GASTRIC BYPASSCOMPLICATIONS

Biliopancreatic Diversion (BPD)

Primarily malabsorptive but restrictive component also

First Terminal ileum is measured to a length of 50 cms marked with suture

The alimentary tract beyond the proximal part of stomach is rearranged to

include only distal 200 cm of ileum including common channel

Common channel-Distal 50 cm of terminal ileum for absorption of fat and

protein

The proximal end of ileum anastomosed to proximal end of stomach after

performing distal hemigastrectomy

Biliopancreatic Diversion with Duodenal Switch

Modification to lessen high incidence of vit b12 deficiency anastomotic stricture at gastrojejunal anastomosis

This procedure involves a sleeve gastrectomy that is then diverted at the duodenum into the ileum at a point measured proximally from the ileocecal valve (usually 250 cm)

The distal duodenum and jejunum the biliopancreatic limb are then anastomosed to the ileum at a point measured proximally from the ileocecal valve (usually 100 cm)

Common channel is 100cm Entire alimentary tract is 250 cm This is the most aggressive bypass procedure commonly offered today Major difference-Sleeve gastrectomy instead of distal hemigastrectomy

bull Most women regained normal menstrual function and most had documented

spontaneous ovulation

bull Significant improvement in hirsutism androgen profiles and about a 50 reduction in

HOMA-IR

bull Follow up for more than 2 years showed that all women resumed normal menstrual

cycles HbA1C decreased from 82 to 51 in lt 3 months

bull 78 saw improvement in metabolic syndrome amp 48 showed improvement in PCOS

2 ROLE OF BARIATRIC SURGERY IN PCOS PATIENTS

bull Decrease menstrual irregularities bull PCOS women have less hyper androgenism

bull Sex hormone binding globulin increases bull LH and FSH levels have been reported to increase

bull Ovulatory function measured by luteal LH and Progesterone secretion improved bull Leptin levels decrease reflecting improved reproductive metabolic status

bull Subclinical hypothyroidism significantly reduced

THE SAFE TIMING OF PREGNANCYoptimal or minimal time gt12 months after bariatric surgery before becoming pregnant in order to allow the rapid weight loss and metabolic changes to subside

4 BARIATRIC SURGERY IN REPRODUCTIVE WOMEN

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)

The foregut hypothesis theory ndash 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

Effect of Bariatric Surgery on Diabetes Mellitus

Combined Gastric Restriction amp Malabsorption

Operative Risks (vs cholecystectomy)

Perioperative Mortality 1-2 vs 02-08 Early Complications 10 vs 29Late Complications 20 vs 1-2

LimitationsWidening of (unbanded) gastrojejunostomyExpansion of gastric pouch 25 with nearly 100 weight regainAdaptation of limb that receives the food

SUMMARY OF ALL TYPES OF SURGERY

bull LRYGBP ndash worlds best procedure 60-70 WL dumping syndrome malnutrition

bull LAGB- low complications varying range of wt loss frequent post-op visits ( 10)

bull DSBPD- more wt loss high complications good for high BMI gt 50 malabsorption +

bull VBG(vertical band gastroplasty) ndash longest available results good wt loss improved co-morbidities right for some ptsrisks too high to justify rewards

bull SG- needs long term research 1st step procedure low risks higher wt loss lesser complications pouch could Stretch over time long staple line could cause problems in future frequency is accelerating because of technical ease 1st stage procedure before bypass

Post-surgical Complications

Anastomosis leaks or staple line leaks Pulmonary Embolism or DVT Cholelithiasis Stomal ulceration Dumping syndrome Constipation

Anastamosis Leaks

Up to 7-10 days after surgery Most common at gastrojejunostomy enteroenterostomy Roux

limb stump staple line Can lead to peritonitis sepsis possible death Presentation

Tachycardia tachypnea Fever Ab painback pain Pelvic pressure or rebound tenderness

Anastamosis Leaks

Order Gastrograffin upper GI series Subclinical cases

Bowel rest Parenteral nutrition IV antibiotic if H pylori

Clinically suspect leak Laparoscopic evaluation and leak repair

Failure to evaluate is the most common cause of preventable major long-term disability or death in bariatric surgical patients

Pulmonary Embolism

Sudden cause of death up to one month after surgery 20-30 mortality rate High risk may have vena cava filter placement prior to surgery Prophylaxis with compression stockings and LMWH Early ambulation imperitive

Pulmonary Embolism

Presentation Profound hypoxia Hypotension Signs of sepsis

Immediate spiral chest CT Abdominal exploration if too large for machine No pathology start anticoagulation Too largehelliphellipNO SURGERY

Cholelithiasis

Up to 36 of patients within 6 months post-op Bile stasis leads to increased sludge and gallstones Prophylactic cholecystectomy prior to surgery if

evidence of existing sludge or stones Prevent post-operative disease with concurrent bariatric

surgery and cholecystectomy Prophylactic use of urosidol

Expensive and unpalatable

Stomal Ulceration

12-15 within 2-4 mos Post-surgery Etiology

Overabundant acid in pouch leads to excessive acid passing through stoma

Pouch tension and staple line breakdown NSAID use

Presentation Dyspepsia vomiting Epigastric or retrosternal pain

Stomal Ulceration

Treatment PPI carafate Antibiotics if H Pylori Avoid NSAIDS alcohol smoking

If no response to treatment Endoscopy Back to surgery for pouch revision or staple line repair

Dumping Syndrome

More than 15 patients Hypotention Tachycardia Lightheadedness syncope Flushing Abdominal cramping and diarrhea Nausea and vomiting

Dumping Syndrome

Occurs with high dose simple sugar ingestion Sugar in small intestine causes osmotic overload and fluid

shift from blood to intestine Increased intestinal volume leads to watery diarrhea Decreased blood volume leads to systemic changes Patient education

Eat slowly Avoid drinking before during and not until 30 minutes after meals

Constipation

Most common complaint Causes

Dehydration and decreased fluid intake post-operatively Increased metabolic water needs Calcium and iron supplement use following surgery

Treat with increased fluids and stool softeners

Nutritional Consequences

Iron deficiency anemia B12 deficiency Folate deficiency Calcium and Vitamin D deficiency

Not seen with purely restrictive surgeries

Iron deficiency and anemia

Common following RYGB As high as 49 of patients Multifactorial cause

Low gastric acid levels prohibit iron cleavage from food Absorption inhibited because no nutrient exposure to duodenum or

proximal jejunum Decrease in iron-rich food consumption due to intolerance

Treat with oral supplementation of ferrous sulfate or ferrous gluconate

Vitamin B12 deficiency

Up to 70 of patients Lack of hydrochloric acid and pepsin in stomach

Prevents B12 cleavage from food Affects secretion of intrinsic factor thus B12 absorption

Intolerance to meat and milk Oral supplementation usually adequate otherwise IM injections used

Folate Deficiency

40 of gastric bypass patients Complete absorption requires B12 Absorption dependent on HCl and upper 13 stomach Deficiency generally caused by decreased consumption Oral supplementation

Vitamin D and Calcium Deficiency

Vitamin D deficiency is common among obese people Calcium absorption decreased because duodenum is

bypassed Intolerance to dairy foods high in calcium Vitamin D is required for Ca++ absorption Prolonged deficiencies lead to

Bone resorption osteomalacia osteoporosis Treat with calcium citrate supplementation and 2 weekly

doses of Vitamin D

Nutritional Implications of Various Bariatric Surgeries(34)

bull RYGB Malabsorption of Vit B12 Vit B1 (thiamin) Vit D Vit K Folate Iron Calcium

bull LAGB Folic Acid deficiency

bull BPD and BPDDS Vit A D E and K deficiency Protein-Calorie Malnutrition Malabsorption of

Calcium Zinc Selenium Sodium Potassium Chloride Phosphorus Magnesium

Recommended Daily Supplements(4)

Multivitamin with iron (prenatal vitamin will have adeq amount of folic acid)

Calcium (citrate) with vitamin D (1200-1500 mg calcium with 800-1000 IU vitamin D)

Oral vitamin B12 (500-1000 mcg) Iron (65 mgday in elemental form)

Vitamin C (to increase absorption of Iron) Thiamin (10 mgday)

Diet Recommendations(3)

Reduce food volume Chew food very well Slow pace of eating No liquids with meals Encourage fruits and vegetables as diet progresses Include high protein foods (at least 60gday) may need protein

supplements

Diet Progression Gastric Bypass

Stage 1 Clear liquids and protein supplement (1 week)

Stage 2No concentrated sweets low fat puree diet ( 3 weeks)

Stage 3 Regular texture weight reduction diet

Diet Progression Lap - Band

Stage 1 Clear liquids and protein supplement ( 2 weeks)

Stage 2 No concentrated sweets low fat puree diet (2weeks)

Stage 3 Regular texture weight reduction diet

Stage 1

Only clear liquids allowed Avoid sweetened beverages Sip very slowly No straws Avoid caffeinated carbonated and alcoholic beverages STOP drinking if you feel fullness pain or discomfort

Protein supplements

Begin the day after you go home from Hospital

Minimum protein target 70gmsday

May use powder or pre-mixed liquid forms (Whey protein is preferred)

Protein pills may not be used

Vitamin and Mineral Supplements

Gastric bypass patients In addition to eating much less food gastric bypass patients will also

absorb vitamins and minerals differently after surgery They will require daily multivitamin calcium and iron

supplementation for the rest of your life

Vitamin and Mineral Supplements

Lap-Bandreg patients

Require a multivitamin with minerals daily

It may be necessary to take additional vitamins and minerals eg calcium iron folateB1 B12These will be prescribed as needed

Stage 2 dietPUREE

Puree diet

Regular scheduled meals Avoid meal skipping Plan meals in advance Eat Slowly Eat protein foods first Moisten meats Use liquid protein as supplement not as meal replacement

Measure 2 oz portions at each meal eating when full Separate liquids and solids No bread rice or pasta Avoid added sugars and high fat

foods VARIETY

Obesity Related Co-Morbidities

Co-Morbidity Diabetes Hypertension Hyperlipidemia Cardiac disease Respiratory disease Obstructive sleep apnea Arthritis Depression Stress Incontinence Joint problems

Occurrence in the Obese 14ndash20 25ndash55 35ndash53 10ndash15

10ndash20 20ndash25 70ndash90 50 50

Pulmonary diseaseabnormal functionobstructive sleep apneahypoventilation syndrome

Nonalcoholic fatty liver diseasesteatosissteatohepatitiscirrhosis

Coronary heart disease Diabetes Dyslipidemia Hypertension

Gynecologic abnormalitiesabnormal mensesinfertilitypolycystic ovarian syndrome

Osteoarthritis

Skin

Gall bladder disease

Cancerbreast uterus cervixcolon esophagus pancreaskidney prostate

Phlebitisvenous stasis

Gout

Medical Complications of Obesity Idiopathic intracranial

hypertensionStroke

Cataracts

Severe pancreatitis

What are your optionsSource Adkinson Am J Clinical Nutrition 1994

1 Diet Exercise Behavioral Changes -up to 10 loss of excess body weight -ineffective long-term less than 5 sustain significant weight loss2 Weight Loss Drugs -minimal sustained weight loss -side effects prevent long-term use3 Weight-Loss Surgery -55 to 75 loss of excess body weight

Guidelines for the Treatment of Overweight and Obese Individuals

Indications for drug treatment

Pharmacological treatments are typically used as an adjunct to diet and exercise for patients with BMI of 30 or greater BMI of ge27 for patients with obesity-related risk factors or

comorbid diseases

Obesity Drugs Appetite suppressants

Noradrenergic (Schedule IV) Phentermine (Adipex Fastin) Diethylpropion (Tenuate)

Noradrenergic (Schedule III) Benzphetamine (Didrex) Phendimetrazine (Bontril)

Serotonergic Fenfluramine dexfenfluramine

Mixed Noradrenergic amp Serotonergic Sibutramine (Meridia)

Nutrient absorption reducers Lipase inhibitor

Orlistat (Xenical)

Sibutramine (Meridia)

Blocks presynaptic receptor uptake of norepinephrine and serotonin thereby potentiating their anorexic effect in the central nervous system

Contraindicated CAD CHF cardiac arrhythmias or stroke Side Effects hypertension arrhythmia tachycardia headache dry

mouth constipation insomnia

Orlistat

Inhibits pancreatic lipase and thereby reduces absorption of up to 30 of ingested dietary fat

Lipase inhibitor reduces fat absorption by ~30 resulting in reduction in energy intake

Inhibits digestion of dietary triglycerides decreases absorption of cholesterol and lipid-soluble vitamins

Side Effects

GI side effects due to inhibition of fat absorption pain fecal urgency liquid stools flatulence with discharge

oily spotting

Why Diets Often Fail

Require lot of time and energy

Cause feelings of deprivation

Donrsquot address why people overeat

Disrupt metabolism

Why SurgeryDiet and exercise are not effective

long term in the morbidly obese Surgery is an accepted and effective approach Medical co-morbidities are improvedresolved Increases life expectancy Decreases health care costs Surgical risk is acceptable vs risk of long-term obesity

RESOLUTION OF DISEASES FOLLOWING BARIATRIC SURGERY

Who Is a Surgical Candidate BMI gt 40 kgm2

-OR- BMI gt 35 kgm2 and major medical complications of

obesity-AND-

Failure of other approaches to long-term weight loss Age 18-55(relative)

Recommended BMI values for Bariatric Surgery in Asians

BMI ge 375

BMI ge 325 with two

associated co-

morbidities

No endocrine cause of obesity Acceptable operative risk Understands surgery and risks Absence of drug or alcohol problem No uncontrolled psychological conditions Consensus after bariatric team

evaluation SurgeonDieticianPsychologistConsultant

Dedicated to life-style change and follow-up

Obesity multidisciplinary team

Surgeon Physician Anesthetist Dietician Specialist bariatric nurse Skilled theatre staff Psychiatrist

Bariatric Surgery and Diabetes

International Diabetes Federation (2011) Journal of Diabetes (3(2011) 261-264) ldquoBariatric surgery is an appropriate treatment of people with T2D and

obesity who are not achieving recommended treatment targets with existing medical therapies especially in the presence of other major comorbiditiesrdquo

lt1 of those eligible actually have WLS for diabetes

Contraindications

Factors that may be considered contraindications include unstable CAD uncontrolled severe OSA uncontrolled psychiatric disorder mental retardation (IQ lt 60) inability to understand the surgery perceived inability to adhere to postoperative restrictions continued drug abuse malignancy with a poor 5-year survival prognosis Cirrhotic liver disease with portal hypertension

Preoperative EvaluationAttention should focus on issues unique to the obese patient

particularly cardiorespiratory status and the airwayConsideration of co morbidities ie hypertension diabetes heart

failure IHD obesity-hypoventilation syndrome metabolic syndrome etc

Results of the sleep study History of previous surgeries their anesthetic challenges need for

ICU admissionCurrent medicationsPatients scheduled for repeat bariatric surgery should be screened

preoperatively for long-term metabolic and nutritional abnormalities

Investigationshellip Recommended preoperative laboratory evaluations include

fasting blood glucose lipid profile electrolytes serum chemistries (to evaluate renal and hepatic function) complete blood count Serum ferritin vitamin B12 thyrotropin amp 25-hydroxyvitamin D

(Miller 7th edition- anesthesia for Bariatic Surgery) ABG measurements help evaluate ventilation as well as the need for perioperative oxygen administration and

postoperative ventilation Routine pulmonary function tests and liver function tests are not cost-effective in asymptomatic obese patients Coaugulation profile ( liver problem repeat surgery orlistat) ECG echocardiography Sleep study if suspected OSA

(Barash 6th edition anesthesia and obesity)

Concurrent Preoperative and Prophylactic Medications

Patients usual medications should be continued until the time of surgery with the possible exception of insulin and oral hypoglycemics

Antibiotic prophylaxis is usually indicated

Obesity itself does not increase the risk for aspiration acid aspiration prophylaxis including H2 receptor agonists or proton pump inhibitors must be considered in patients with identifiable risk for aspiration

Anxiolysis and prophylaxis against deep vein thrombosis (DVT) should be addressed at premedication

DVT consideration Morbid obesity is a major independent risk factor for sudden death from

acute postoperative pulmonary embolism Subcutaneous heparin 5000 IU administered before surgery and repeated every 8 to 12

hours until the patient is fully mobile reduces the risk of DVT LMWH can also be used

Preoperative prophylactic placement of an inferior vena cava filter should be considered in venous stasis disease BMI ge60 truncal obesity and OSA

What Are the Risks

MAJOR RISKS Death (1 of patients die within 30 days) Severe malnutrition (anemia PEM osteomalacia) Peritonitis (from leakage or ruptures at staple sites)

or other infection Obstructions caused by scar tissue in the stomach or

bowels

MINOR RISKS Dumping Syndrome (unpleasant but not harmful) Diarrhea and malodorous gas production Lactose intolerance Hair loss (short-term post-surgery) May have to eventually undergo surgical revision Pain post-surgery

History of Bariatric Surgery

Obesity surgery is not a new discipline The earliest Bariatric procedure performed was in 1954 at Minnesota The procedure

was Jejuno-ileal bypass In 1966Gastric Bypass was introduced as a surgical procedure for weight loss at the

University of Iowa In 1977Griffen reported the first Roux-en-Y Gastric Bypass In 1980surgeons with a more conservative approach developed the Vertical Banded

Gastroplasty Other procedures with longer intestinal segment bypass were also introduced such as

Biliopancreatic Diversions These complex procedures are recommended in super-obese patients ie BMIgt60

How does surgery work

RESTRICTIVE - RESTRICT AMOUNT OF FOOD INGESTED Decreases appetitehunger

Early satiety Behavior modification Gastric Banding (Lap Band)

Roux-en Y Gastric bypass (RYGB) Sleeve Gastrectomy

MALABSORPTIVE- LIMITS DIGESTION AND ABSORPTION Decreases length of intestine exposed to digested food

25 of fat is absorbed Behavior modification

Biliopancreatic Diversion Duodenal Switch (BPDDS)

ALL OPERATIONS CAN BE PERFORMED OPEN OR LAPAROSCOPICALLY

Laparoscopic vs Open

OPEN uarr post op pain Longer hospitalizations uarr wound complications

Infection Hernias Seromas

Return to work in 4-8 weeks

LAPAROSCOPIC darr post op pain Early mobility darr Wound complications 2-3 day hospital stay Return to work in 1-3 weeks

1 Nguyen NT et al Accelerated growth of bariatric surgery with the introduction of minimally invasive surgery Arch Surg 20051401198-202

Procedures that are solely restrictive by creating a small gastric pouch of volume 15 to 30 cc amp a degree of outlet obstruction leading to delayed gastric emptying The goal is to reduce oral intake by limiting gastric volume produce early satiety and leave the alimentary canal in continuity minimizing the risks of metabolic complications

1VERTICAL BANDED GASTROPLASTY

2ADJUSTABLE GASTRIC BANDING (LAGB )

3 SLEEVE GASTRECTOMY

4GASTRIC PLICATION

5 INTRA GASTRIC BALLOON (GASTRIC BALLOON)

RESTRICTIVE PROCEDURES

Malabsorption is achieved by creating a short gut syndrome andor by accomplishing distal mixing of bile and pancreatic juice with ingested nutrients thereby reducing absorption Some purely malabsorptive operations are no longer recommended due to their potential hazard to cause serious nutritional deficiencies

1 BILIOPANCREATIC DIVERSION2 THE JEJUNAL-ILEAL BYPASS3 ENDOLUMINAL SLEEVE

MALABSORPTIVE PROCEDURES

MIXED PROCEDURES

1GASTRIC BYPASS ROUX-EN-Y ( RYGBP)

2SLEEVE GASTRECTOMY WITH DUODENAL SWITCH

3IMPLANTABLE 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

The stomach is partitioned along its axis with a non-

adjustable poly-urethane band and with linear amp 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 was practiced in 1980

Vertical Banded Gastroplasty (VBG)

ADJUSTABLE GASTRIC BANDING (LAP BAND SURGERY LAGB)

Restrictive Procedure The procedure was first performed by Cadiere in 1992 but was made popular by Belachew and Legrand in 1993 An inflatable silicone BAND is placed around the top portion of the stomach to form a small stomach pouch amp sewed

This band is connected to a tube that leads to a port above the abdominal muscles placed below the skin (FILL ndash PORT)

During follow up visits we inject or remove saline solution to make the band tighter or looser

Adjustable Gastric Band

bull 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

How does the Band work

Surgery Factors Restriction of meal size Decreased appetite

Patient Factors Decreased calorie intake Increased calorie expenditure

LAP-BAND Adjustability

Unfilled Band Filled Band

Adjustments are made in the office

Complications of Gastric Lap-Band

bull Perforation of Stomachbull Slippagebull Gastric Erosion(much less after Pars flaccida technique) bull Dilated Esophagusbull Tubing access port problemsbull Mal positioningbull Abdominal Painbull Heartburnbull Vomitingbull Inability to Adjust the Bandbull Failure to Lose Weightbull Infection of Systembull Fatigue or malfunction

Advantages

No intestinal surgery No staplingcutting of stomach No nutritional risks Adjustable Reversible Safe

Foreign body Frequent follow-up visits Needs more commitment Easy to cheat

Disadvantages

Comparison of Adjustable Gastric Banding and Vertical Banded Gastroplasty

Laparoscopic adjustable gastric banding Reversible Adjustable Simpler to perform laparoscopically Sustained weight loss of gt50 EBW gt5

years following surgery Complications Gastric prolapse band

erosion rarely gastric perforation and access port complications

Vertical banded gastroplasty Irreversible Non adjustable Technically difficult by laparoscopy Weight loss of 25-50 EBW and weight gain

after 2-3 years Complications suture line disruption gastric

leak weight gain

>

>

Originally used as the first-stage operation for a proposed biliopancreatic diversion with duodenal switch in high-risk patients

The sleeve gastrectomy has caught on as a primary obesity treatment as surgeons are reporting weight loss of 55 of excess body weight past 5 years in some patients

The sleeve gastrectomy is also known as the greater curvature gastrectomy vertical or longitudinal gastrectomy or Pylorus preserving lsquogastric tube creationrsquo

Rapid and less traumatic operation Good resolution of co-morbidities and good weight loss

A further second surgical step is then easily feasible if necessary

SLEEVE GASTRECTOMY

SLEEVE GASTRECTOMY

A sleeve gastrectomy involves resection of

approximately 80 of the greater curvature

side of the stomach

Smaller tubular gastric ldquosleeverdquo created

along the lesser curve that is based on the

lesser curvature blood supply

Ideal approximate capacity of the stomach

after the procedure is about 30- 60 ml pouch

1MECHANICAL RESTRICTION by reducing the volume of the stomach and impairing stomach mobility Also called lsquoFood limitingrsquo operation

2HORMONAL MODIFICATION by removing a great part of the Ghrelin (Hunger Hormone) production tissue

(Ghrelin is a 28 amino-acid-peptide secreted by the oxyntic glands of the gastric fungus It is a potent orexigenic (appetite-stimulating) peptide mediated by the activation of its receptors in the hypothalamus or pituitary area)

The gastric fundus contains 10 to 20 times more ghrelin per one gram of tissue than the duodenum In the SG resection of the fundus removes the major portion of ghrelin release therefore appetite decreases

The sleeve gastrectomy (SG) induces weight loss by 2 mechanisms

>

Intragastric balloon involves placing a deflated balloon into the stomach and then filling it to decrease the amount of gastric space

The balloon can be left in the stomach for a maximum of 6 months and results in an average weight loss of 5ndash9 BMI over half a year

Done endoscopically

The intragastric balloon may be used prior to another bariatric surgery as a step-down procedure

INTRA GASTRIC BALLOON

>

>

The EndoBarrier gastrointestinal liner mimics the effects of gastric bypass surgery

Itrsquos designed to work by inserting a flexible

tube-like barrier into the duodenum amp 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

ENDO BARRIER LINER SYSTEM

B MAL- ABSORPTIVE PROCEDURES

Malabsorptive surgeries rearrange andor remove part of digestive system which then limits the amount of calories and nutrients that body can absorb Treatment with a large malabsorptive component results in the most weight loss but tend to have slightly higher complication rates

1JEJUNAL ILEAL BYPASS ndash no longer performed for high complication rates

2ILEAL TRANSPOSITION- New malabsoptive procedure on trial for treatment of DM type 2 and metabolic disorders

C COMBINATION PROCEDURES RESTRICTIVE + MALABSORBTIVE

1LAP GASTRIC BYPASS ndash ROUX-EN- Y ndash more malabsorption than the restrictive

2MINI- GASTRIC BYPASS- mainly restrictive

3DUODENAL SWITCH ndash the sleeve stomach is the restrictive portion ampthe intestinal bypass (duodenal switch) is the malabsorptive component

When surgery combines both restrictive and malabsorptive techniques it is know as a ldquocombinationrdquo procedure Most types of bariatric surgery carry at least a small element of both components but the following surgeries achieve a notable portion of weight loss from eachhellip

1 LAP GASTRIC BYPASS LGB

The Roux-en-Y gastric bypass(known simply as the LRYGBP) is the most commonly performed procedure

It primarily causesweight loss by restricting thefood intake however there ismore amount of mal absorption that occurs with this operation

GASTRIC BYPASS LRYGBP

bullThe stomach is stapled into2 pieces one small and one large The small piece becomes the ldquonewrdquo stomach pouch

bull The larger portion of the stomach stays in place however will lie dormant for the remainder of the patientrsquos life

GASTRIC BYPASS LGB

bull The small intestine (the jejunum) is divided using a surgical staplerApprox 50-70 cm from the DJ Junction

GASTRIC BYPASS LGB

Y- LIMB BP LIMB

bull The end of the Roux limb is then attached to the newly formed stomach pouch which carries food to the distal intestine

bull The Roux loop is completed by forming a jejunostomy

bull The Y limb or BPD limb carries digestive juices from the pancreas gall bladder liver and duodenum to the intestines

bull The food and the digestive juices mix where the Roux limb and Y limb meet much below say 100-150 cm from DJ

Roux limb or alimentary limb

100-150 cm

How Does the Roux-en-Y Work

Surgery factors restriction of meal size ldquodumping syndromerdquo some malabsorption decreased appetite

Patient factors calorie intake calorie expenditure

bull Most commonly performedbull Most reliable operation for long term weight lossbull Long term weight loss averages 60 to 75 percent of EBWbull Malnutrition is unusualbull Substantial improvement amp resolution in many co-morbid

obesity conditions

ADVANTAGES OF RYGBP

1 Not reversible

2 Mortality 05- 1

3 Perioperative complications 5-10

4 Stricture of gastrojejunostomy-10 (long term)

5 Long term risk of protein amp vitamin deficiency and marginal ulceration of GJA

6Long term risk of intestinal obstruction ndash 2

LAPAROSCOPIC GASTRIC BYPASSCOMPLICATIONS

Biliopancreatic Diversion (BPD)

Primarily malabsorptive but restrictive component also

First Terminal ileum is measured to a length of 50 cms marked with suture

The alimentary tract beyond the proximal part of stomach is rearranged to

include only distal 200 cm of ileum including common channel

Common channel-Distal 50 cm of terminal ileum for absorption of fat and

protein

The proximal end of ileum anastomosed to proximal end of stomach after

performing distal hemigastrectomy

Biliopancreatic Diversion with Duodenal Switch

Modification to lessen high incidence of vit b12 deficiency anastomotic stricture at gastrojejunal anastomosis

This procedure involves a sleeve gastrectomy that is then diverted at the duodenum into the ileum at a point measured proximally from the ileocecal valve (usually 250 cm)

The distal duodenum and jejunum the biliopancreatic limb are then anastomosed to the ileum at a point measured proximally from the ileocecal valve (usually 100 cm)

Common channel is 100cm Entire alimentary tract is 250 cm This is the most aggressive bypass procedure commonly offered today Major difference-Sleeve gastrectomy instead of distal hemigastrectomy

bull Most women regained normal menstrual function and most had documented

spontaneous ovulation

bull Significant improvement in hirsutism androgen profiles and about a 50 reduction in

HOMA-IR

bull Follow up for more than 2 years showed that all women resumed normal menstrual

cycles HbA1C decreased from 82 to 51 in lt 3 months

bull 78 saw improvement in metabolic syndrome amp 48 showed improvement in PCOS

2 ROLE OF BARIATRIC SURGERY IN PCOS PATIENTS

bull Decrease menstrual irregularities bull PCOS women have less hyper androgenism

bull Sex hormone binding globulin increases bull LH and FSH levels have been reported to increase

bull Ovulatory function measured by luteal LH and Progesterone secretion improved bull Leptin levels decrease reflecting improved reproductive metabolic status

bull Subclinical hypothyroidism significantly reduced

THE SAFE TIMING OF PREGNANCYoptimal or minimal time gt12 months after bariatric surgery before becoming pregnant in order to allow the rapid weight loss and metabolic changes to subside

4 BARIATRIC SURGERY IN REPRODUCTIVE WOMEN

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)

The foregut hypothesis theory ndash 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

Effect of Bariatric Surgery on Diabetes Mellitus

Combined Gastric Restriction amp Malabsorption

Operative Risks (vs cholecystectomy)

Perioperative Mortality 1-2 vs 02-08 Early Complications 10 vs 29Late Complications 20 vs 1-2

LimitationsWidening of (unbanded) gastrojejunostomyExpansion of gastric pouch 25 with nearly 100 weight regainAdaptation of limb that receives the food

SUMMARY OF ALL TYPES OF SURGERY

bull LRYGBP ndash worlds best procedure 60-70 WL dumping syndrome malnutrition

bull LAGB- low complications varying range of wt loss frequent post-op visits ( 10)

bull DSBPD- more wt loss high complications good for high BMI gt 50 malabsorption +

bull VBG(vertical band gastroplasty) ndash longest available results good wt loss improved co-morbidities right for some ptsrisks too high to justify rewards

bull SG- needs long term research 1st step procedure low risks higher wt loss lesser complications pouch could Stretch over time long staple line could cause problems in future frequency is accelerating because of technical ease 1st stage procedure before bypass

Post-surgical Complications

Anastomosis leaks or staple line leaks Pulmonary Embolism or DVT Cholelithiasis Stomal ulceration Dumping syndrome Constipation

Anastamosis Leaks

Up to 7-10 days after surgery Most common at gastrojejunostomy enteroenterostomy Roux

limb stump staple line Can lead to peritonitis sepsis possible death Presentation

Tachycardia tachypnea Fever Ab painback pain Pelvic pressure or rebound tenderness

Anastamosis Leaks

Order Gastrograffin upper GI series Subclinical cases

Bowel rest Parenteral nutrition IV antibiotic if H pylori

Clinically suspect leak Laparoscopic evaluation and leak repair

Failure to evaluate is the most common cause of preventable major long-term disability or death in bariatric surgical patients

Pulmonary Embolism

Sudden cause of death up to one month after surgery 20-30 mortality rate High risk may have vena cava filter placement prior to surgery Prophylaxis with compression stockings and LMWH Early ambulation imperitive

Pulmonary Embolism

Presentation Profound hypoxia Hypotension Signs of sepsis

Immediate spiral chest CT Abdominal exploration if too large for machine No pathology start anticoagulation Too largehelliphellipNO SURGERY

Cholelithiasis

Up to 36 of patients within 6 months post-op Bile stasis leads to increased sludge and gallstones Prophylactic cholecystectomy prior to surgery if

evidence of existing sludge or stones Prevent post-operative disease with concurrent bariatric

surgery and cholecystectomy Prophylactic use of urosidol

Expensive and unpalatable

Stomal Ulceration

12-15 within 2-4 mos Post-surgery Etiology

Overabundant acid in pouch leads to excessive acid passing through stoma

Pouch tension and staple line breakdown NSAID use

Presentation Dyspepsia vomiting Epigastric or retrosternal pain

Stomal Ulceration

Treatment PPI carafate Antibiotics if H Pylori Avoid NSAIDS alcohol smoking

If no response to treatment Endoscopy Back to surgery for pouch revision or staple line repair

Dumping Syndrome

More than 15 patients Hypotention Tachycardia Lightheadedness syncope Flushing Abdominal cramping and diarrhea Nausea and vomiting

Dumping Syndrome

Occurs with high dose simple sugar ingestion Sugar in small intestine causes osmotic overload and fluid

shift from blood to intestine Increased intestinal volume leads to watery diarrhea Decreased blood volume leads to systemic changes Patient education

Eat slowly Avoid drinking before during and not until 30 minutes after meals

Constipation

Most common complaint Causes

Dehydration and decreased fluid intake post-operatively Increased metabolic water needs Calcium and iron supplement use following surgery

Treat with increased fluids and stool softeners

Nutritional Consequences

Iron deficiency anemia B12 deficiency Folate deficiency Calcium and Vitamin D deficiency

Not seen with purely restrictive surgeries

Iron deficiency and anemia

Common following RYGB As high as 49 of patients Multifactorial cause

Low gastric acid levels prohibit iron cleavage from food Absorption inhibited because no nutrient exposure to duodenum or

proximal jejunum Decrease in iron-rich food consumption due to intolerance

Treat with oral supplementation of ferrous sulfate or ferrous gluconate

Vitamin B12 deficiency

Up to 70 of patients Lack of hydrochloric acid and pepsin in stomach

Prevents B12 cleavage from food Affects secretion of intrinsic factor thus B12 absorption

Intolerance to meat and milk Oral supplementation usually adequate otherwise IM injections used

Folate Deficiency

40 of gastric bypass patients Complete absorption requires B12 Absorption dependent on HCl and upper 13 stomach Deficiency generally caused by decreased consumption Oral supplementation

Vitamin D and Calcium Deficiency

Vitamin D deficiency is common among obese people Calcium absorption decreased because duodenum is

bypassed Intolerance to dairy foods high in calcium Vitamin D is required for Ca++ absorption Prolonged deficiencies lead to

Bone resorption osteomalacia osteoporosis Treat with calcium citrate supplementation and 2 weekly

doses of Vitamin D

Nutritional Implications of Various Bariatric Surgeries(34)

bull RYGB Malabsorption of Vit B12 Vit B1 (thiamin) Vit D Vit K Folate Iron Calcium

bull LAGB Folic Acid deficiency

bull BPD and BPDDS Vit A D E and K deficiency Protein-Calorie Malnutrition Malabsorption of

Calcium Zinc Selenium Sodium Potassium Chloride Phosphorus Magnesium

Recommended Daily Supplements(4)

Multivitamin with iron (prenatal vitamin will have adeq amount of folic acid)

Calcium (citrate) with vitamin D (1200-1500 mg calcium with 800-1000 IU vitamin D)

Oral vitamin B12 (500-1000 mcg) Iron (65 mgday in elemental form)

Vitamin C (to increase absorption of Iron) Thiamin (10 mgday)

Diet Recommendations(3)

Reduce food volume Chew food very well Slow pace of eating No liquids with meals Encourage fruits and vegetables as diet progresses Include high protein foods (at least 60gday) may need protein

supplements

Diet Progression Gastric Bypass

Stage 1 Clear liquids and protein supplement (1 week)

Stage 2No concentrated sweets low fat puree diet ( 3 weeks)

Stage 3 Regular texture weight reduction diet

Diet Progression Lap - Band

Stage 1 Clear liquids and protein supplement ( 2 weeks)

Stage 2 No concentrated sweets low fat puree diet (2weeks)

Stage 3 Regular texture weight reduction diet

Stage 1

Only clear liquids allowed Avoid sweetened beverages Sip very slowly No straws Avoid caffeinated carbonated and alcoholic beverages STOP drinking if you feel fullness pain or discomfort

Protein supplements

Begin the day after you go home from Hospital

Minimum protein target 70gmsday

May use powder or pre-mixed liquid forms (Whey protein is preferred)

Protein pills may not be used

Vitamin and Mineral Supplements

Gastric bypass patients In addition to eating much less food gastric bypass patients will also

absorb vitamins and minerals differently after surgery They will require daily multivitamin calcium and iron

supplementation for the rest of your life

Vitamin and Mineral Supplements

Lap-Bandreg patients

Require a multivitamin with minerals daily

It may be necessary to take additional vitamins and minerals eg calcium iron folateB1 B12These will be prescribed as needed

Stage 2 dietPUREE

Puree diet

Regular scheduled meals Avoid meal skipping Plan meals in advance Eat Slowly Eat protein foods first Moisten meats Use liquid protein as supplement not as meal replacement

Measure 2 oz portions at each meal eating when full Separate liquids and solids No bread rice or pasta Avoid added sugars and high fat

foods VARIETY

Pulmonary diseaseabnormal functionobstructive sleep apneahypoventilation syndrome

Nonalcoholic fatty liver diseasesteatosissteatohepatitiscirrhosis

Coronary heart disease Diabetes Dyslipidemia Hypertension

Gynecologic abnormalitiesabnormal mensesinfertilitypolycystic ovarian syndrome

Osteoarthritis

Skin

Gall bladder disease

Cancerbreast uterus cervixcolon esophagus pancreaskidney prostate

Phlebitisvenous stasis

Gout

Medical Complications of Obesity Idiopathic intracranial

hypertensionStroke

Cataracts

Severe pancreatitis

What are your optionsSource Adkinson Am J Clinical Nutrition 1994

1 Diet Exercise Behavioral Changes -up to 10 loss of excess body weight -ineffective long-term less than 5 sustain significant weight loss2 Weight Loss Drugs -minimal sustained weight loss -side effects prevent long-term use3 Weight-Loss Surgery -55 to 75 loss of excess body weight

Guidelines for the Treatment of Overweight and Obese Individuals

Indications for drug treatment

Pharmacological treatments are typically used as an adjunct to diet and exercise for patients with BMI of 30 or greater BMI of ge27 for patients with obesity-related risk factors or

comorbid diseases

Obesity Drugs Appetite suppressants

Noradrenergic (Schedule IV) Phentermine (Adipex Fastin) Diethylpropion (Tenuate)

Noradrenergic (Schedule III) Benzphetamine (Didrex) Phendimetrazine (Bontril)

Serotonergic Fenfluramine dexfenfluramine

Mixed Noradrenergic amp Serotonergic Sibutramine (Meridia)

Nutrient absorption reducers Lipase inhibitor

Orlistat (Xenical)

Sibutramine (Meridia)

Blocks presynaptic receptor uptake of norepinephrine and serotonin thereby potentiating their anorexic effect in the central nervous system

Contraindicated CAD CHF cardiac arrhythmias or stroke Side Effects hypertension arrhythmia tachycardia headache dry

mouth constipation insomnia

Orlistat

Inhibits pancreatic lipase and thereby reduces absorption of up to 30 of ingested dietary fat

Lipase inhibitor reduces fat absorption by ~30 resulting in reduction in energy intake

Inhibits digestion of dietary triglycerides decreases absorption of cholesterol and lipid-soluble vitamins

Side Effects

GI side effects due to inhibition of fat absorption pain fecal urgency liquid stools flatulence with discharge

oily spotting

Why Diets Often Fail

Require lot of time and energy

Cause feelings of deprivation

Donrsquot address why people overeat

Disrupt metabolism

Why SurgeryDiet and exercise are not effective

long term in the morbidly obese Surgery is an accepted and effective approach Medical co-morbidities are improvedresolved Increases life expectancy Decreases health care costs Surgical risk is acceptable vs risk of long-term obesity

RESOLUTION OF DISEASES FOLLOWING BARIATRIC SURGERY

Who Is a Surgical Candidate BMI gt 40 kgm2

-OR- BMI gt 35 kgm2 and major medical complications of

obesity-AND-

Failure of other approaches to long-term weight loss Age 18-55(relative)

Recommended BMI values for Bariatric Surgery in Asians

BMI ge 375

BMI ge 325 with two

associated co-

morbidities

No endocrine cause of obesity Acceptable operative risk Understands surgery and risks Absence of drug or alcohol problem No uncontrolled psychological conditions Consensus after bariatric team

evaluation SurgeonDieticianPsychologistConsultant

Dedicated to life-style change and follow-up

Obesity multidisciplinary team

Surgeon Physician Anesthetist Dietician Specialist bariatric nurse Skilled theatre staff Psychiatrist

Bariatric Surgery and Diabetes

International Diabetes Federation (2011) Journal of Diabetes (3(2011) 261-264) ldquoBariatric surgery is an appropriate treatment of people with T2D and

obesity who are not achieving recommended treatment targets with existing medical therapies especially in the presence of other major comorbiditiesrdquo

lt1 of those eligible actually have WLS for diabetes

Contraindications

Factors that may be considered contraindications include unstable CAD uncontrolled severe OSA uncontrolled psychiatric disorder mental retardation (IQ lt 60) inability to understand the surgery perceived inability to adhere to postoperative restrictions continued drug abuse malignancy with a poor 5-year survival prognosis Cirrhotic liver disease with portal hypertension

Preoperative EvaluationAttention should focus on issues unique to the obese patient

particularly cardiorespiratory status and the airwayConsideration of co morbidities ie hypertension diabetes heart

failure IHD obesity-hypoventilation syndrome metabolic syndrome etc

Results of the sleep study History of previous surgeries their anesthetic challenges need for

ICU admissionCurrent medicationsPatients scheduled for repeat bariatric surgery should be screened

preoperatively for long-term metabolic and nutritional abnormalities

Investigationshellip Recommended preoperative laboratory evaluations include

fasting blood glucose lipid profile electrolytes serum chemistries (to evaluate renal and hepatic function) complete blood count Serum ferritin vitamin B12 thyrotropin amp 25-hydroxyvitamin D

(Miller 7th edition- anesthesia for Bariatic Surgery) ABG measurements help evaluate ventilation as well as the need for perioperative oxygen administration and

postoperative ventilation Routine pulmonary function tests and liver function tests are not cost-effective in asymptomatic obese patients Coaugulation profile ( liver problem repeat surgery orlistat) ECG echocardiography Sleep study if suspected OSA

(Barash 6th edition anesthesia and obesity)

Concurrent Preoperative and Prophylactic Medications

Patients usual medications should be continued until the time of surgery with the possible exception of insulin and oral hypoglycemics

Antibiotic prophylaxis is usually indicated

Obesity itself does not increase the risk for aspiration acid aspiration prophylaxis including H2 receptor agonists or proton pump inhibitors must be considered in patients with identifiable risk for aspiration

Anxiolysis and prophylaxis against deep vein thrombosis (DVT) should be addressed at premedication

DVT consideration Morbid obesity is a major independent risk factor for sudden death from

acute postoperative pulmonary embolism Subcutaneous heparin 5000 IU administered before surgery and repeated every 8 to 12

hours until the patient is fully mobile reduces the risk of DVT LMWH can also be used

Preoperative prophylactic placement of an inferior vena cava filter should be considered in venous stasis disease BMI ge60 truncal obesity and OSA

What Are the Risks

MAJOR RISKS Death (1 of patients die within 30 days) Severe malnutrition (anemia PEM osteomalacia) Peritonitis (from leakage or ruptures at staple sites)

or other infection Obstructions caused by scar tissue in the stomach or

bowels

MINOR RISKS Dumping Syndrome (unpleasant but not harmful) Diarrhea and malodorous gas production Lactose intolerance Hair loss (short-term post-surgery) May have to eventually undergo surgical revision Pain post-surgery

History of Bariatric Surgery

Obesity surgery is not a new discipline The earliest Bariatric procedure performed was in 1954 at Minnesota The procedure

was Jejuno-ileal bypass In 1966Gastric Bypass was introduced as a surgical procedure for weight loss at the

University of Iowa In 1977Griffen reported the first Roux-en-Y Gastric Bypass In 1980surgeons with a more conservative approach developed the Vertical Banded

Gastroplasty Other procedures with longer intestinal segment bypass were also introduced such as

Biliopancreatic Diversions These complex procedures are recommended in super-obese patients ie BMIgt60

How does surgery work

RESTRICTIVE - RESTRICT AMOUNT OF FOOD INGESTED Decreases appetitehunger

Early satiety Behavior modification Gastric Banding (Lap Band)

Roux-en Y Gastric bypass (RYGB) Sleeve Gastrectomy

MALABSORPTIVE- LIMITS DIGESTION AND ABSORPTION Decreases length of intestine exposed to digested food

25 of fat is absorbed Behavior modification

Biliopancreatic Diversion Duodenal Switch (BPDDS)

ALL OPERATIONS CAN BE PERFORMED OPEN OR LAPAROSCOPICALLY

Laparoscopic vs Open

OPEN uarr post op pain Longer hospitalizations uarr wound complications

Infection Hernias Seromas

Return to work in 4-8 weeks

LAPAROSCOPIC darr post op pain Early mobility darr Wound complications 2-3 day hospital stay Return to work in 1-3 weeks

1 Nguyen NT et al Accelerated growth of bariatric surgery with the introduction of minimally invasive surgery Arch Surg 20051401198-202

Procedures that are solely restrictive by creating a small gastric pouch of volume 15 to 30 cc amp a degree of outlet obstruction leading to delayed gastric emptying The goal is to reduce oral intake by limiting gastric volume produce early satiety and leave the alimentary canal in continuity minimizing the risks of metabolic complications

1VERTICAL BANDED GASTROPLASTY

2ADJUSTABLE GASTRIC BANDING (LAGB )

3 SLEEVE GASTRECTOMY

4GASTRIC PLICATION

5 INTRA GASTRIC BALLOON (GASTRIC BALLOON)

RESTRICTIVE PROCEDURES

Malabsorption is achieved by creating a short gut syndrome andor by accomplishing distal mixing of bile and pancreatic juice with ingested nutrients thereby reducing absorption Some purely malabsorptive operations are no longer recommended due to their potential hazard to cause serious nutritional deficiencies

1 BILIOPANCREATIC DIVERSION2 THE JEJUNAL-ILEAL BYPASS3 ENDOLUMINAL SLEEVE

MALABSORPTIVE PROCEDURES

MIXED PROCEDURES

1GASTRIC BYPASS ROUX-EN-Y ( RYGBP)

2SLEEVE GASTRECTOMY WITH DUODENAL SWITCH

3IMPLANTABLE 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

The stomach is partitioned along its axis with a non-

adjustable poly-urethane band and with linear amp 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 was practiced in 1980

Vertical Banded Gastroplasty (VBG)

ADJUSTABLE GASTRIC BANDING (LAP BAND SURGERY LAGB)

Restrictive Procedure The procedure was first performed by Cadiere in 1992 but was made popular by Belachew and Legrand in 1993 An inflatable silicone BAND is placed around the top portion of the stomach to form a small stomach pouch amp sewed

This band is connected to a tube that leads to a port above the abdominal muscles placed below the skin (FILL ndash PORT)

During follow up visits we inject or remove saline solution to make the band tighter or looser

Adjustable Gastric Band

bull 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

How does the Band work

Surgery Factors Restriction of meal size Decreased appetite

Patient Factors Decreased calorie intake Increased calorie expenditure

LAP-BAND Adjustability

Unfilled Band Filled Band

Adjustments are made in the office

Complications of Gastric Lap-Band

bull Perforation of Stomachbull Slippagebull Gastric Erosion(much less after Pars flaccida technique) bull Dilated Esophagusbull Tubing access port problemsbull Mal positioningbull Abdominal Painbull Heartburnbull Vomitingbull Inability to Adjust the Bandbull Failure to Lose Weightbull Infection of Systembull Fatigue or malfunction

Advantages

No intestinal surgery No staplingcutting of stomach No nutritional risks Adjustable Reversible Safe

Foreign body Frequent follow-up visits Needs more commitment Easy to cheat

Disadvantages

Comparison of Adjustable Gastric Banding and Vertical Banded Gastroplasty

Laparoscopic adjustable gastric banding Reversible Adjustable Simpler to perform laparoscopically Sustained weight loss of gt50 EBW gt5

years following surgery Complications Gastric prolapse band

erosion rarely gastric perforation and access port complications

Vertical banded gastroplasty Irreversible Non adjustable Technically difficult by laparoscopy Weight loss of 25-50 EBW and weight gain

after 2-3 years Complications suture line disruption gastric

leak weight gain

>

>

Originally used as the first-stage operation for a proposed biliopancreatic diversion with duodenal switch in high-risk patients

The sleeve gastrectomy has caught on as a primary obesity treatment as surgeons are reporting weight loss of 55 of excess body weight past 5 years in some patients

The sleeve gastrectomy is also known as the greater curvature gastrectomy vertical or longitudinal gastrectomy or Pylorus preserving lsquogastric tube creationrsquo

Rapid and less traumatic operation Good resolution of co-morbidities and good weight loss

A further second surgical step is then easily feasible if necessary

SLEEVE GASTRECTOMY

SLEEVE GASTRECTOMY

A sleeve gastrectomy involves resection of

approximately 80 of the greater curvature

side of the stomach

Smaller tubular gastric ldquosleeverdquo created

along the lesser curve that is based on the

lesser curvature blood supply

Ideal approximate capacity of the stomach

after the procedure is about 30- 60 ml pouch

1MECHANICAL RESTRICTION by reducing the volume of the stomach and impairing stomach mobility Also called lsquoFood limitingrsquo operation

2HORMONAL MODIFICATION by removing a great part of the Ghrelin (Hunger Hormone) production tissue

(Ghrelin is a 28 amino-acid-peptide secreted by the oxyntic glands of the gastric fungus It is a potent orexigenic (appetite-stimulating) peptide mediated by the activation of its receptors in the hypothalamus or pituitary area)

The gastric fundus contains 10 to 20 times more ghrelin per one gram of tissue than the duodenum In the SG resection of the fundus removes the major portion of ghrelin release therefore appetite decreases

The sleeve gastrectomy (SG) induces weight loss by 2 mechanisms

>

Intragastric balloon involves placing a deflated balloon into the stomach and then filling it to decrease the amount of gastric space

The balloon can be left in the stomach for a maximum of 6 months and results in an average weight loss of 5ndash9 BMI over half a year

Done endoscopically

The intragastric balloon may be used prior to another bariatric surgery as a step-down procedure

INTRA GASTRIC BALLOON

>

>

The EndoBarrier gastrointestinal liner mimics the effects of gastric bypass surgery

Itrsquos designed to work by inserting a flexible

tube-like barrier into the duodenum amp 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

ENDO BARRIER LINER SYSTEM

B MAL- ABSORPTIVE PROCEDURES

Malabsorptive surgeries rearrange andor remove part of digestive system which then limits the amount of calories and nutrients that body can absorb Treatment with a large malabsorptive component results in the most weight loss but tend to have slightly higher complication rates

1JEJUNAL ILEAL BYPASS ndash no longer performed for high complication rates

2ILEAL TRANSPOSITION- New malabsoptive procedure on trial for treatment of DM type 2 and metabolic disorders

C COMBINATION PROCEDURES RESTRICTIVE + MALABSORBTIVE

1LAP GASTRIC BYPASS ndash ROUX-EN- Y ndash more malabsorption than the restrictive

2MINI- GASTRIC BYPASS- mainly restrictive

3DUODENAL SWITCH ndash the sleeve stomach is the restrictive portion ampthe intestinal bypass (duodenal switch) is the malabsorptive component

When surgery combines both restrictive and malabsorptive techniques it is know as a ldquocombinationrdquo procedure Most types of bariatric surgery carry at least a small element of both components but the following surgeries achieve a notable portion of weight loss from eachhellip

1 LAP GASTRIC BYPASS LGB

The Roux-en-Y gastric bypass(known simply as the LRYGBP) is the most commonly performed procedure

It primarily causesweight loss by restricting thefood intake however there ismore amount of mal absorption that occurs with this operation

GASTRIC BYPASS LRYGBP

bullThe stomach is stapled into2 pieces one small and one large The small piece becomes the ldquonewrdquo stomach pouch

bull The larger portion of the stomach stays in place however will lie dormant for the remainder of the patientrsquos life

GASTRIC BYPASS LGB

bull The small intestine (the jejunum) is divided using a surgical staplerApprox 50-70 cm from the DJ Junction

GASTRIC BYPASS LGB

Y- LIMB BP LIMB

bull The end of the Roux limb is then attached to the newly formed stomach pouch which carries food to the distal intestine

bull The Roux loop is completed by forming a jejunostomy

bull The Y limb or BPD limb carries digestive juices from the pancreas gall bladder liver and duodenum to the intestines

bull The food and the digestive juices mix where the Roux limb and Y limb meet much below say 100-150 cm from DJ

Roux limb or alimentary limb

100-150 cm

How Does the Roux-en-Y Work

Surgery factors restriction of meal size ldquodumping syndromerdquo some malabsorption decreased appetite

Patient factors calorie intake calorie expenditure

bull Most commonly performedbull Most reliable operation for long term weight lossbull Long term weight loss averages 60 to 75 percent of EBWbull Malnutrition is unusualbull Substantial improvement amp resolution in many co-morbid

obesity conditions

ADVANTAGES OF RYGBP

1 Not reversible

2 Mortality 05- 1

3 Perioperative complications 5-10

4 Stricture of gastrojejunostomy-10 (long term)

5 Long term risk of protein amp vitamin deficiency and marginal ulceration of GJA

6Long term risk of intestinal obstruction ndash 2

LAPAROSCOPIC GASTRIC BYPASSCOMPLICATIONS

Biliopancreatic Diversion (BPD)

Primarily malabsorptive but restrictive component also

First Terminal ileum is measured to a length of 50 cms marked with suture

The alimentary tract beyond the proximal part of stomach is rearranged to

include only distal 200 cm of ileum including common channel

Common channel-Distal 50 cm of terminal ileum for absorption of fat and

protein

The proximal end of ileum anastomosed to proximal end of stomach after

performing distal hemigastrectomy

Biliopancreatic Diversion with Duodenal Switch

Modification to lessen high incidence of vit b12 deficiency anastomotic stricture at gastrojejunal anastomosis

This procedure involves a sleeve gastrectomy that is then diverted at the duodenum into the ileum at a point measured proximally from the ileocecal valve (usually 250 cm)

The distal duodenum and jejunum the biliopancreatic limb are then anastomosed to the ileum at a point measured proximally from the ileocecal valve (usually 100 cm)

Common channel is 100cm Entire alimentary tract is 250 cm This is the most aggressive bypass procedure commonly offered today Major difference-Sleeve gastrectomy instead of distal hemigastrectomy

bull Most women regained normal menstrual function and most had documented

spontaneous ovulation

bull Significant improvement in hirsutism androgen profiles and about a 50 reduction in

HOMA-IR

bull Follow up for more than 2 years showed that all women resumed normal menstrual

cycles HbA1C decreased from 82 to 51 in lt 3 months

bull 78 saw improvement in metabolic syndrome amp 48 showed improvement in PCOS

2 ROLE OF BARIATRIC SURGERY IN PCOS PATIENTS

bull Decrease menstrual irregularities bull PCOS women have less hyper androgenism

bull Sex hormone binding globulin increases bull LH and FSH levels have been reported to increase

bull Ovulatory function measured by luteal LH and Progesterone secretion improved bull Leptin levels decrease reflecting improved reproductive metabolic status

bull Subclinical hypothyroidism significantly reduced

THE SAFE TIMING OF PREGNANCYoptimal or minimal time gt12 months after bariatric surgery before becoming pregnant in order to allow the rapid weight loss and metabolic changes to subside

4 BARIATRIC SURGERY IN REPRODUCTIVE WOMEN

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)

The foregut hypothesis theory ndash 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

Effect of Bariatric Surgery on Diabetes Mellitus

Combined Gastric Restriction amp Malabsorption

Operative Risks (vs cholecystectomy)

Perioperative Mortality 1-2 vs 02-08 Early Complications 10 vs 29Late Complications 20 vs 1-2

LimitationsWidening of (unbanded) gastrojejunostomyExpansion of gastric pouch 25 with nearly 100 weight regainAdaptation of limb that receives the food

SUMMARY OF ALL TYPES OF SURGERY

bull LRYGBP ndash worlds best procedure 60-70 WL dumping syndrome malnutrition

bull LAGB- low complications varying range of wt loss frequent post-op visits ( 10)

bull DSBPD- more wt loss high complications good for high BMI gt 50 malabsorption +

bull VBG(vertical band gastroplasty) ndash longest available results good wt loss improved co-morbidities right for some ptsrisks too high to justify rewards

bull SG- needs long term research 1st step procedure low risks higher wt loss lesser complications pouch could Stretch over time long staple line could cause problems in future frequency is accelerating because of technical ease 1st stage procedure before bypass

Post-surgical Complications

Anastomosis leaks or staple line leaks Pulmonary Embolism or DVT Cholelithiasis Stomal ulceration Dumping syndrome Constipation

Anastamosis Leaks

Up to 7-10 days after surgery Most common at gastrojejunostomy enteroenterostomy Roux

limb stump staple line Can lead to peritonitis sepsis possible death Presentation

Tachycardia tachypnea Fever Ab painback pain Pelvic pressure or rebound tenderness

Anastamosis Leaks

Order Gastrograffin upper GI series Subclinical cases

Bowel rest Parenteral nutrition IV antibiotic if H pylori

Clinically suspect leak Laparoscopic evaluation and leak repair

Failure to evaluate is the most common cause of preventable major long-term disability or death in bariatric surgical patients

Pulmonary Embolism

Sudden cause of death up to one month after surgery 20-30 mortality rate High risk may have vena cava filter placement prior to surgery Prophylaxis with compression stockings and LMWH Early ambulation imperitive

Pulmonary Embolism

Presentation Profound hypoxia Hypotension Signs of sepsis

Immediate spiral chest CT Abdominal exploration if too large for machine No pathology start anticoagulation Too largehelliphellipNO SURGERY

Cholelithiasis

Up to 36 of patients within 6 months post-op Bile stasis leads to increased sludge and gallstones Prophylactic cholecystectomy prior to surgery if

evidence of existing sludge or stones Prevent post-operative disease with concurrent bariatric

surgery and cholecystectomy Prophylactic use of urosidol

Expensive and unpalatable

Stomal Ulceration

12-15 within 2-4 mos Post-surgery Etiology

Overabundant acid in pouch leads to excessive acid passing through stoma

Pouch tension and staple line breakdown NSAID use

Presentation Dyspepsia vomiting Epigastric or retrosternal pain

Stomal Ulceration

Treatment PPI carafate Antibiotics if H Pylori Avoid NSAIDS alcohol smoking

If no response to treatment Endoscopy Back to surgery for pouch revision or staple line repair

Dumping Syndrome

More than 15 patients Hypotention Tachycardia Lightheadedness syncope Flushing Abdominal cramping and diarrhea Nausea and vomiting

Dumping Syndrome

Occurs with high dose simple sugar ingestion Sugar in small intestine causes osmotic overload and fluid

shift from blood to intestine Increased intestinal volume leads to watery diarrhea Decreased blood volume leads to systemic changes Patient education

Eat slowly Avoid drinking before during and not until 30 minutes after meals

Constipation

Most common complaint Causes

Dehydration and decreased fluid intake post-operatively Increased metabolic water needs Calcium and iron supplement use following surgery

Treat with increased fluids and stool softeners

Nutritional Consequences

Iron deficiency anemia B12 deficiency Folate deficiency Calcium and Vitamin D deficiency

Not seen with purely restrictive surgeries

Iron deficiency and anemia

Common following RYGB As high as 49 of patients Multifactorial cause

Low gastric acid levels prohibit iron cleavage from food Absorption inhibited because no nutrient exposure to duodenum or

proximal jejunum Decrease in iron-rich food consumption due to intolerance

Treat with oral supplementation of ferrous sulfate or ferrous gluconate

Vitamin B12 deficiency

Up to 70 of patients Lack of hydrochloric acid and pepsin in stomach

Prevents B12 cleavage from food Affects secretion of intrinsic factor thus B12 absorption

Intolerance to meat and milk Oral supplementation usually adequate otherwise IM injections used

Folate Deficiency

40 of gastric bypass patients Complete absorption requires B12 Absorption dependent on HCl and upper 13 stomach Deficiency generally caused by decreased consumption Oral supplementation

Vitamin D and Calcium Deficiency

Vitamin D deficiency is common among obese people Calcium absorption decreased because duodenum is

bypassed Intolerance to dairy foods high in calcium Vitamin D is required for Ca++ absorption Prolonged deficiencies lead to

Bone resorption osteomalacia osteoporosis Treat with calcium citrate supplementation and 2 weekly

doses of Vitamin D

Nutritional Implications of Various Bariatric Surgeries(34)

bull RYGB Malabsorption of Vit B12 Vit B1 (thiamin) Vit D Vit K Folate Iron Calcium

bull LAGB Folic Acid deficiency

bull BPD and BPDDS Vit A D E and K deficiency Protein-Calorie Malnutrition Malabsorption of

Calcium Zinc Selenium Sodium Potassium Chloride Phosphorus Magnesium

Recommended Daily Supplements(4)

Multivitamin with iron (prenatal vitamin will have adeq amount of folic acid)

Calcium (citrate) with vitamin D (1200-1500 mg calcium with 800-1000 IU vitamin D)

Oral vitamin B12 (500-1000 mcg) Iron (65 mgday in elemental form)

Vitamin C (to increase absorption of Iron) Thiamin (10 mgday)

Diet Recommendations(3)

Reduce food volume Chew food very well Slow pace of eating No liquids with meals Encourage fruits and vegetables as diet progresses Include high protein foods (at least 60gday) may need protein

supplements

Diet Progression Gastric Bypass

Stage 1 Clear liquids and protein supplement (1 week)

Stage 2No concentrated sweets low fat puree diet ( 3 weeks)

Stage 3 Regular texture weight reduction diet

Diet Progression Lap - Band

Stage 1 Clear liquids and protein supplement ( 2 weeks)

Stage 2 No concentrated sweets low fat puree diet (2weeks)

Stage 3 Regular texture weight reduction diet

Stage 1

Only clear liquids allowed Avoid sweetened beverages Sip very slowly No straws Avoid caffeinated carbonated and alcoholic beverages STOP drinking if you feel fullness pain or discomfort

Protein supplements

Begin the day after you go home from Hospital

Minimum protein target 70gmsday

May use powder or pre-mixed liquid forms (Whey protein is preferred)

Protein pills may not be used

Vitamin and Mineral Supplements

Gastric bypass patients In addition to eating much less food gastric bypass patients will also

absorb vitamins and minerals differently after surgery They will require daily multivitamin calcium and iron

supplementation for the rest of your life

Vitamin and Mineral Supplements

Lap-Bandreg patients

Require a multivitamin with minerals daily

It may be necessary to take additional vitamins and minerals eg calcium iron folateB1 B12These will be prescribed as needed

Stage 2 dietPUREE

Puree diet

Regular scheduled meals Avoid meal skipping Plan meals in advance Eat Slowly Eat protein foods first Moisten meats Use liquid protein as supplement not as meal replacement

Measure 2 oz portions at each meal eating when full Separate liquids and solids No bread rice or pasta Avoid added sugars and high fat

foods VARIETY

What are your optionsSource Adkinson Am J Clinical Nutrition 1994

1 Diet Exercise Behavioral Changes -up to 10 loss of excess body weight -ineffective long-term less than 5 sustain significant weight loss2 Weight Loss Drugs -minimal sustained weight loss -side effects prevent long-term use3 Weight-Loss Surgery -55 to 75 loss of excess body weight

Guidelines for the Treatment of Overweight and Obese Individuals

Indications for drug treatment

Pharmacological treatments are typically used as an adjunct to diet and exercise for patients with BMI of 30 or greater BMI of ge27 for patients with obesity-related risk factors or

comorbid diseases

Obesity Drugs Appetite suppressants

Noradrenergic (Schedule IV) Phentermine (Adipex Fastin) Diethylpropion (Tenuate)

Noradrenergic (Schedule III) Benzphetamine (Didrex) Phendimetrazine (Bontril)

Serotonergic Fenfluramine dexfenfluramine

Mixed Noradrenergic amp Serotonergic Sibutramine (Meridia)

Nutrient absorption reducers Lipase inhibitor

Orlistat (Xenical)

Sibutramine (Meridia)

Blocks presynaptic receptor uptake of norepinephrine and serotonin thereby potentiating their anorexic effect in the central nervous system

Contraindicated CAD CHF cardiac arrhythmias or stroke Side Effects hypertension arrhythmia tachycardia headache dry

mouth constipation insomnia

Orlistat

Inhibits pancreatic lipase and thereby reduces absorption of up to 30 of ingested dietary fat

Lipase inhibitor reduces fat absorption by ~30 resulting in reduction in energy intake

Inhibits digestion of dietary triglycerides decreases absorption of cholesterol and lipid-soluble vitamins

Side Effects

GI side effects due to inhibition of fat absorption pain fecal urgency liquid stools flatulence with discharge

oily spotting

Why Diets Often Fail

Require lot of time and energy

Cause feelings of deprivation

Donrsquot address why people overeat

Disrupt metabolism

Why SurgeryDiet and exercise are not effective

long term in the morbidly obese Surgery is an accepted and effective approach Medical co-morbidities are improvedresolved Increases life expectancy Decreases health care costs Surgical risk is acceptable vs risk of long-term obesity

RESOLUTION OF DISEASES FOLLOWING BARIATRIC SURGERY

Who Is a Surgical Candidate BMI gt 40 kgm2

-OR- BMI gt 35 kgm2 and major medical complications of

obesity-AND-

Failure of other approaches to long-term weight loss Age 18-55(relative)

Recommended BMI values for Bariatric Surgery in Asians

BMI ge 375

BMI ge 325 with two

associated co-

morbidities

No endocrine cause of obesity Acceptable operative risk Understands surgery and risks Absence of drug or alcohol problem No uncontrolled psychological conditions Consensus after bariatric team

evaluation SurgeonDieticianPsychologistConsultant

Dedicated to life-style change and follow-up

Obesity multidisciplinary team

Surgeon Physician Anesthetist Dietician Specialist bariatric nurse Skilled theatre staff Psychiatrist

Bariatric Surgery and Diabetes

International Diabetes Federation (2011) Journal of Diabetes (3(2011) 261-264) ldquoBariatric surgery is an appropriate treatment of people with T2D and

obesity who are not achieving recommended treatment targets with existing medical therapies especially in the presence of other major comorbiditiesrdquo

lt1 of those eligible actually have WLS for diabetes

Contraindications

Factors that may be considered contraindications include unstable CAD uncontrolled severe OSA uncontrolled psychiatric disorder mental retardation (IQ lt 60) inability to understand the surgery perceived inability to adhere to postoperative restrictions continued drug abuse malignancy with a poor 5-year survival prognosis Cirrhotic liver disease with portal hypertension

Preoperative EvaluationAttention should focus on issues unique to the obese patient

particularly cardiorespiratory status and the airwayConsideration of co morbidities ie hypertension diabetes heart

failure IHD obesity-hypoventilation syndrome metabolic syndrome etc

Results of the sleep study History of previous surgeries their anesthetic challenges need for

ICU admissionCurrent medicationsPatients scheduled for repeat bariatric surgery should be screened

preoperatively for long-term metabolic and nutritional abnormalities

Investigationshellip Recommended preoperative laboratory evaluations include

fasting blood glucose lipid profile electrolytes serum chemistries (to evaluate renal and hepatic function) complete blood count Serum ferritin vitamin B12 thyrotropin amp 25-hydroxyvitamin D

(Miller 7th edition- anesthesia for Bariatic Surgery) ABG measurements help evaluate ventilation as well as the need for perioperative oxygen administration and

postoperative ventilation Routine pulmonary function tests and liver function tests are not cost-effective in asymptomatic obese patients Coaugulation profile ( liver problem repeat surgery orlistat) ECG echocardiography Sleep study if suspected OSA

(Barash 6th edition anesthesia and obesity)

Concurrent Preoperative and Prophylactic Medications

Patients usual medications should be continued until the time of surgery with the possible exception of insulin and oral hypoglycemics

Antibiotic prophylaxis is usually indicated

Obesity itself does not increase the risk for aspiration acid aspiration prophylaxis including H2 receptor agonists or proton pump inhibitors must be considered in patients with identifiable risk for aspiration

Anxiolysis and prophylaxis against deep vein thrombosis (DVT) should be addressed at premedication

DVT consideration Morbid obesity is a major independent risk factor for sudden death from

acute postoperative pulmonary embolism Subcutaneous heparin 5000 IU administered before surgery and repeated every 8 to 12

hours until the patient is fully mobile reduces the risk of DVT LMWH can also be used

Preoperative prophylactic placement of an inferior vena cava filter should be considered in venous stasis disease BMI ge60 truncal obesity and OSA

What Are the Risks

MAJOR RISKS Death (1 of patients die within 30 days) Severe malnutrition (anemia PEM osteomalacia) Peritonitis (from leakage or ruptures at staple sites)

or other infection Obstructions caused by scar tissue in the stomach or

bowels

MINOR RISKS Dumping Syndrome (unpleasant but not harmful) Diarrhea and malodorous gas production Lactose intolerance Hair loss (short-term post-surgery) May have to eventually undergo surgical revision Pain post-surgery

History of Bariatric Surgery

Obesity surgery is not a new discipline The earliest Bariatric procedure performed was in 1954 at Minnesota The procedure

was Jejuno-ileal bypass In 1966Gastric Bypass was introduced as a surgical procedure for weight loss at the

University of Iowa In 1977Griffen reported the first Roux-en-Y Gastric Bypass In 1980surgeons with a more conservative approach developed the Vertical Banded

Gastroplasty Other procedures with longer intestinal segment bypass were also introduced such as

Biliopancreatic Diversions These complex procedures are recommended in super-obese patients ie BMIgt60

How does surgery work

RESTRICTIVE - RESTRICT AMOUNT OF FOOD INGESTED Decreases appetitehunger

Early satiety Behavior modification Gastric Banding (Lap Band)

Roux-en Y Gastric bypass (RYGB) Sleeve Gastrectomy

MALABSORPTIVE- LIMITS DIGESTION AND ABSORPTION Decreases length of intestine exposed to digested food

25 of fat is absorbed Behavior modification

Biliopancreatic Diversion Duodenal Switch (BPDDS)

ALL OPERATIONS CAN BE PERFORMED OPEN OR LAPAROSCOPICALLY

Laparoscopic vs Open

OPEN uarr post op pain Longer hospitalizations uarr wound complications

Infection Hernias Seromas

Return to work in 4-8 weeks

LAPAROSCOPIC darr post op pain Early mobility darr Wound complications 2-3 day hospital stay Return to work in 1-3 weeks

1 Nguyen NT et al Accelerated growth of bariatric surgery with the introduction of minimally invasive surgery Arch Surg 20051401198-202

Procedures that are solely restrictive by creating a small gastric pouch of volume 15 to 30 cc amp a degree of outlet obstruction leading to delayed gastric emptying The goal is to reduce oral intake by limiting gastric volume produce early satiety and leave the alimentary canal in continuity minimizing the risks of metabolic complications

1VERTICAL BANDED GASTROPLASTY

2ADJUSTABLE GASTRIC BANDING (LAGB )

3 SLEEVE GASTRECTOMY

4GASTRIC PLICATION

5 INTRA GASTRIC BALLOON (GASTRIC BALLOON)

RESTRICTIVE PROCEDURES

Malabsorption is achieved by creating a short gut syndrome andor by accomplishing distal mixing of bile and pancreatic juice with ingested nutrients thereby reducing absorption Some purely malabsorptive operations are no longer recommended due to their potential hazard to cause serious nutritional deficiencies

1 BILIOPANCREATIC DIVERSION2 THE JEJUNAL-ILEAL BYPASS3 ENDOLUMINAL SLEEVE

MALABSORPTIVE PROCEDURES

MIXED PROCEDURES

1GASTRIC BYPASS ROUX-EN-Y ( RYGBP)

2SLEEVE GASTRECTOMY WITH DUODENAL SWITCH

3IMPLANTABLE 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

The stomach is partitioned along its axis with a non-

adjustable poly-urethane band and with linear amp 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 was practiced in 1980

Vertical Banded Gastroplasty (VBG)

ADJUSTABLE GASTRIC BANDING (LAP BAND SURGERY LAGB)

Restrictive Procedure The procedure was first performed by Cadiere in 1992 but was made popular by Belachew and Legrand in 1993 An inflatable silicone BAND is placed around the top portion of the stomach to form a small stomach pouch amp sewed

This band is connected to a tube that leads to a port above the abdominal muscles placed below the skin (FILL ndash PORT)

During follow up visits we inject or remove saline solution to make the band tighter or looser

Adjustable Gastric Band

bull 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

How does the Band work

Surgery Factors Restriction of meal size Decreased appetite

Patient Factors Decreased calorie intake Increased calorie expenditure

LAP-BAND Adjustability

Unfilled Band Filled Band

Adjustments are made in the office

Complications of Gastric Lap-Band

bull Perforation of Stomachbull Slippagebull Gastric Erosion(much less after Pars flaccida technique) bull Dilated Esophagusbull Tubing access port problemsbull Mal positioningbull Abdominal Painbull Heartburnbull Vomitingbull Inability to Adjust the Bandbull Failure to Lose Weightbull Infection of Systembull Fatigue or malfunction

Advantages

No intestinal surgery No staplingcutting of stomach No nutritional risks Adjustable Reversible Safe

Foreign body Frequent follow-up visits Needs more commitment Easy to cheat

Disadvantages

Comparison of Adjustable Gastric Banding and Vertical Banded Gastroplasty

Laparoscopic adjustable gastric banding Reversible Adjustable Simpler to perform laparoscopically Sustained weight loss of gt50 EBW gt5

years following surgery Complications Gastric prolapse band

erosion rarely gastric perforation and access port complications

Vertical banded gastroplasty Irreversible Non adjustable Technically difficult by laparoscopy Weight loss of 25-50 EBW and weight gain

after 2-3 years Complications suture line disruption gastric

leak weight gain

>

>

Originally used as the first-stage operation for a proposed biliopancreatic diversion with duodenal switch in high-risk patients

The sleeve gastrectomy has caught on as a primary obesity treatment as surgeons are reporting weight loss of 55 of excess body weight past 5 years in some patients

The sleeve gastrectomy is also known as the greater curvature gastrectomy vertical or longitudinal gastrectomy or Pylorus preserving lsquogastric tube creationrsquo

Rapid and less traumatic operation Good resolution of co-morbidities and good weight loss

A further second surgical step is then easily feasible if necessary

SLEEVE GASTRECTOMY

SLEEVE GASTRECTOMY

A sleeve gastrectomy involves resection of

approximately 80 of the greater curvature

side of the stomach

Smaller tubular gastric ldquosleeverdquo created

along the lesser curve that is based on the

lesser curvature blood supply

Ideal approximate capacity of the stomach

after the procedure is about 30- 60 ml pouch

1MECHANICAL RESTRICTION by reducing the volume of the stomach and impairing stomach mobility Also called lsquoFood limitingrsquo operation

2HORMONAL MODIFICATION by removing a great part of the Ghrelin (Hunger Hormone) production tissue

(Ghrelin is a 28 amino-acid-peptide secreted by the oxyntic glands of the gastric fungus It is a potent orexigenic (appetite-stimulating) peptide mediated by the activation of its receptors in the hypothalamus or pituitary area)

The gastric fundus contains 10 to 20 times more ghrelin per one gram of tissue than the duodenum In the SG resection of the fundus removes the major portion of ghrelin release therefore appetite decreases

The sleeve gastrectomy (SG) induces weight loss by 2 mechanisms

>

Intragastric balloon involves placing a deflated balloon into the stomach and then filling it to decrease the amount of gastric space

The balloon can be left in the stomach for a maximum of 6 months and results in an average weight loss of 5ndash9 BMI over half a year

Done endoscopically

The intragastric balloon may be used prior to another bariatric surgery as a step-down procedure

INTRA GASTRIC BALLOON

>

>

The EndoBarrier gastrointestinal liner mimics the effects of gastric bypass surgery

Itrsquos designed to work by inserting a flexible

tube-like barrier into the duodenum amp 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

ENDO BARRIER LINER SYSTEM

B MAL- ABSORPTIVE PROCEDURES

Malabsorptive surgeries rearrange andor remove part of digestive system which then limits the amount of calories and nutrients that body can absorb Treatment with a large malabsorptive component results in the most weight loss but tend to have slightly higher complication rates

1JEJUNAL ILEAL BYPASS ndash no longer performed for high complication rates

2ILEAL TRANSPOSITION- New malabsoptive procedure on trial for treatment of DM type 2 and metabolic disorders

C COMBINATION PROCEDURES RESTRICTIVE + MALABSORBTIVE

1LAP GASTRIC BYPASS ndash ROUX-EN- Y ndash more malabsorption than the restrictive

2MINI- GASTRIC BYPASS- mainly restrictive

3DUODENAL SWITCH ndash the sleeve stomach is the restrictive portion ampthe intestinal bypass (duodenal switch) is the malabsorptive component

When surgery combines both restrictive and malabsorptive techniques it is know as a ldquocombinationrdquo procedure Most types of bariatric surgery carry at least a small element of both components but the following surgeries achieve a notable portion of weight loss from eachhellip

1 LAP GASTRIC BYPASS LGB

The Roux-en-Y gastric bypass(known simply as the LRYGBP) is the most commonly performed procedure

It primarily causesweight loss by restricting thefood intake however there ismore amount of mal absorption that occurs with this operation

GASTRIC BYPASS LRYGBP

bullThe stomach is stapled into2 pieces one small and one large The small piece becomes the ldquonewrdquo stomach pouch

bull The larger portion of the stomach stays in place however will lie dormant for the remainder of the patientrsquos life

GASTRIC BYPASS LGB

bull The small intestine (the jejunum) is divided using a surgical staplerApprox 50-70 cm from the DJ Junction

GASTRIC BYPASS LGB

Y- LIMB BP LIMB

bull The end of the Roux limb is then attached to the newly formed stomach pouch which carries food to the distal intestine

bull The Roux loop is completed by forming a jejunostomy

bull The Y limb or BPD limb carries digestive juices from the pancreas gall bladder liver and duodenum to the intestines

bull The food and the digestive juices mix where the Roux limb and Y limb meet much below say 100-150 cm from DJ

Roux limb or alimentary limb

100-150 cm

How Does the Roux-en-Y Work

Surgery factors restriction of meal size ldquodumping syndromerdquo some malabsorption decreased appetite

Patient factors calorie intake calorie expenditure

bull Most commonly performedbull Most reliable operation for long term weight lossbull Long term weight loss averages 60 to 75 percent of EBWbull Malnutrition is unusualbull Substantial improvement amp resolution in many co-morbid

obesity conditions

ADVANTAGES OF RYGBP

1 Not reversible

2 Mortality 05- 1

3 Perioperative complications 5-10

4 Stricture of gastrojejunostomy-10 (long term)

5 Long term risk of protein amp vitamin deficiency and marginal ulceration of GJA

6Long term risk of intestinal obstruction ndash 2

LAPAROSCOPIC GASTRIC BYPASSCOMPLICATIONS

Biliopancreatic Diversion (BPD)

Primarily malabsorptive but restrictive component also

First Terminal ileum is measured to a length of 50 cms marked with suture

The alimentary tract beyond the proximal part of stomach is rearranged to

include only distal 200 cm of ileum including common channel

Common channel-Distal 50 cm of terminal ileum for absorption of fat and

protein

The proximal end of ileum anastomosed to proximal end of stomach after

performing distal hemigastrectomy

Biliopancreatic Diversion with Duodenal Switch

Modification to lessen high incidence of vit b12 deficiency anastomotic stricture at gastrojejunal anastomosis

This procedure involves a sleeve gastrectomy that is then diverted at the duodenum into the ileum at a point measured proximally from the ileocecal valve (usually 250 cm)

The distal duodenum and jejunum the biliopancreatic limb are then anastomosed to the ileum at a point measured proximally from the ileocecal valve (usually 100 cm)

Common channel is 100cm Entire alimentary tract is 250 cm This is the most aggressive bypass procedure commonly offered today Major difference-Sleeve gastrectomy instead of distal hemigastrectomy

bull Most women regained normal menstrual function and most had documented

spontaneous ovulation

bull Significant improvement in hirsutism androgen profiles and about a 50 reduction in

HOMA-IR

bull Follow up for more than 2 years showed that all women resumed normal menstrual

cycles HbA1C decreased from 82 to 51 in lt 3 months

bull 78 saw improvement in metabolic syndrome amp 48 showed improvement in PCOS

2 ROLE OF BARIATRIC SURGERY IN PCOS PATIENTS

bull Decrease menstrual irregularities bull PCOS women have less hyper androgenism

bull Sex hormone binding globulin increases bull LH and FSH levels have been reported to increase

bull Ovulatory function measured by luteal LH and Progesterone secretion improved bull Leptin levels decrease reflecting improved reproductive metabolic status

bull Subclinical hypothyroidism significantly reduced

THE SAFE TIMING OF PREGNANCYoptimal or minimal time gt12 months after bariatric surgery before becoming pregnant in order to allow the rapid weight loss and metabolic changes to subside

4 BARIATRIC SURGERY IN REPRODUCTIVE WOMEN

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)

The foregut hypothesis theory ndash 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

Effect of Bariatric Surgery on Diabetes Mellitus

Combined Gastric Restriction amp Malabsorption

Operative Risks (vs cholecystectomy)

Perioperative Mortality 1-2 vs 02-08 Early Complications 10 vs 29Late Complications 20 vs 1-2

LimitationsWidening of (unbanded) gastrojejunostomyExpansion of gastric pouch 25 with nearly 100 weight regainAdaptation of limb that receives the food

SUMMARY OF ALL TYPES OF SURGERY

bull LRYGBP ndash worlds best procedure 60-70 WL dumping syndrome malnutrition

bull LAGB- low complications varying range of wt loss frequent post-op visits ( 10)

bull DSBPD- more wt loss high complications good for high BMI gt 50 malabsorption +

bull VBG(vertical band gastroplasty) ndash longest available results good wt loss improved co-morbidities right for some ptsrisks too high to justify rewards

bull SG- needs long term research 1st step procedure low risks higher wt loss lesser complications pouch could Stretch over time long staple line could cause problems in future frequency is accelerating because of technical ease 1st stage procedure before bypass

Post-surgical Complications

Anastomosis leaks or staple line leaks Pulmonary Embolism or DVT Cholelithiasis Stomal ulceration Dumping syndrome Constipation

Anastamosis Leaks

Up to 7-10 days after surgery Most common at gastrojejunostomy enteroenterostomy Roux

limb stump staple line Can lead to peritonitis sepsis possible death Presentation

Tachycardia tachypnea Fever Ab painback pain Pelvic pressure or rebound tenderness

Anastamosis Leaks

Order Gastrograffin upper GI series Subclinical cases

Bowel rest Parenteral nutrition IV antibiotic if H pylori

Clinically suspect leak Laparoscopic evaluation and leak repair

Failure to evaluate is the most common cause of preventable major long-term disability or death in bariatric surgical patients

Pulmonary Embolism

Sudden cause of death up to one month after surgery 20-30 mortality rate High risk may have vena cava filter placement prior to surgery Prophylaxis with compression stockings and LMWH Early ambulation imperitive

Pulmonary Embolism

Presentation Profound hypoxia Hypotension Signs of sepsis

Immediate spiral chest CT Abdominal exploration if too large for machine No pathology start anticoagulation Too largehelliphellipNO SURGERY

Cholelithiasis

Up to 36 of patients within 6 months post-op Bile stasis leads to increased sludge and gallstones Prophylactic cholecystectomy prior to surgery if

evidence of existing sludge or stones Prevent post-operative disease with concurrent bariatric

surgery and cholecystectomy Prophylactic use of urosidol

Expensive and unpalatable

Stomal Ulceration

12-15 within 2-4 mos Post-surgery Etiology

Overabundant acid in pouch leads to excessive acid passing through stoma

Pouch tension and staple line breakdown NSAID use

Presentation Dyspepsia vomiting Epigastric or retrosternal pain

Stomal Ulceration

Treatment PPI carafate Antibiotics if H Pylori Avoid NSAIDS alcohol smoking

If no response to treatment Endoscopy Back to surgery for pouch revision or staple line repair

Dumping Syndrome

More than 15 patients Hypotention Tachycardia Lightheadedness syncope Flushing Abdominal cramping and diarrhea Nausea and vomiting

Dumping Syndrome

Occurs with high dose simple sugar ingestion Sugar in small intestine causes osmotic overload and fluid

shift from blood to intestine Increased intestinal volume leads to watery diarrhea Decreased blood volume leads to systemic changes Patient education

Eat slowly Avoid drinking before during and not until 30 minutes after meals

Constipation

Most common complaint Causes

Dehydration and decreased fluid intake post-operatively Increased metabolic water needs Calcium and iron supplement use following surgery

Treat with increased fluids and stool softeners

Nutritional Consequences

Iron deficiency anemia B12 deficiency Folate deficiency Calcium and Vitamin D deficiency

Not seen with purely restrictive surgeries

Iron deficiency and anemia

Common following RYGB As high as 49 of patients Multifactorial cause

Low gastric acid levels prohibit iron cleavage from food Absorption inhibited because no nutrient exposure to duodenum or

proximal jejunum Decrease in iron-rich food consumption due to intolerance

Treat with oral supplementation of ferrous sulfate or ferrous gluconate

Vitamin B12 deficiency

Up to 70 of patients Lack of hydrochloric acid and pepsin in stomach

Prevents B12 cleavage from food Affects secretion of intrinsic factor thus B12 absorption

Intolerance to meat and milk Oral supplementation usually adequate otherwise IM injections used

Folate Deficiency

40 of gastric bypass patients Complete absorption requires B12 Absorption dependent on HCl and upper 13 stomach Deficiency generally caused by decreased consumption Oral supplementation

Vitamin D and Calcium Deficiency

Vitamin D deficiency is common among obese people Calcium absorption decreased because duodenum is

bypassed Intolerance to dairy foods high in calcium Vitamin D is required for Ca++ absorption Prolonged deficiencies lead to

Bone resorption osteomalacia osteoporosis Treat with calcium citrate supplementation and 2 weekly

doses of Vitamin D

Nutritional Implications of Various Bariatric Surgeries(34)

bull RYGB Malabsorption of Vit B12 Vit B1 (thiamin) Vit D Vit K Folate Iron Calcium

bull LAGB Folic Acid deficiency

bull BPD and BPDDS Vit A D E and K deficiency Protein-Calorie Malnutrition Malabsorption of

Calcium Zinc Selenium Sodium Potassium Chloride Phosphorus Magnesium

Recommended Daily Supplements(4)

Multivitamin with iron (prenatal vitamin will have adeq amount of folic acid)

Calcium (citrate) with vitamin D (1200-1500 mg calcium with 800-1000 IU vitamin D)

Oral vitamin B12 (500-1000 mcg) Iron (65 mgday in elemental form)

Vitamin C (to increase absorption of Iron) Thiamin (10 mgday)

Diet Recommendations(3)

Reduce food volume Chew food very well Slow pace of eating No liquids with meals Encourage fruits and vegetables as diet progresses Include high protein foods (at least 60gday) may need protein

supplements

Diet Progression Gastric Bypass

Stage 1 Clear liquids and protein supplement (1 week)

Stage 2No concentrated sweets low fat puree diet ( 3 weeks)

Stage 3 Regular texture weight reduction diet

Diet Progression Lap - Band

Stage 1 Clear liquids and protein supplement ( 2 weeks)

Stage 2 No concentrated sweets low fat puree diet (2weeks)

Stage 3 Regular texture weight reduction diet

Stage 1

Only clear liquids allowed Avoid sweetened beverages Sip very slowly No straws Avoid caffeinated carbonated and alcoholic beverages STOP drinking if you feel fullness pain or discomfort

Protein supplements

Begin the day after you go home from Hospital

Minimum protein target 70gmsday

May use powder or pre-mixed liquid forms (Whey protein is preferred)

Protein pills may not be used

Vitamin and Mineral Supplements

Gastric bypass patients In addition to eating much less food gastric bypass patients will also

absorb vitamins and minerals differently after surgery They will require daily multivitamin calcium and iron

supplementation for the rest of your life

Vitamin and Mineral Supplements

Lap-Bandreg patients

Require a multivitamin with minerals daily

It may be necessary to take additional vitamins and minerals eg calcium iron folateB1 B12These will be prescribed as needed

Stage 2 dietPUREE

Puree diet

Regular scheduled meals Avoid meal skipping Plan meals in advance Eat Slowly Eat protein foods first Moisten meats Use liquid protein as supplement not as meal replacement

Measure 2 oz portions at each meal eating when full Separate liquids and solids No bread rice or pasta Avoid added sugars and high fat

foods VARIETY

Guidelines for the Treatment of Overweight and Obese Individuals

Indications for drug treatment

Pharmacological treatments are typically used as an adjunct to diet and exercise for patients with BMI of 30 or greater BMI of ge27 for patients with obesity-related risk factors or

comorbid diseases

Obesity Drugs Appetite suppressants

Noradrenergic (Schedule IV) Phentermine (Adipex Fastin) Diethylpropion (Tenuate)

Noradrenergic (Schedule III) Benzphetamine (Didrex) Phendimetrazine (Bontril)

Serotonergic Fenfluramine dexfenfluramine

Mixed Noradrenergic amp Serotonergic Sibutramine (Meridia)

Nutrient absorption reducers Lipase inhibitor

Orlistat (Xenical)

Sibutramine (Meridia)

Blocks presynaptic receptor uptake of norepinephrine and serotonin thereby potentiating their anorexic effect in the central nervous system

Contraindicated CAD CHF cardiac arrhythmias or stroke Side Effects hypertension arrhythmia tachycardia headache dry

mouth constipation insomnia

Orlistat

Inhibits pancreatic lipase and thereby reduces absorption of up to 30 of ingested dietary fat

Lipase inhibitor reduces fat absorption by ~30 resulting in reduction in energy intake

Inhibits digestion of dietary triglycerides decreases absorption of cholesterol and lipid-soluble vitamins

Side Effects

GI side effects due to inhibition of fat absorption pain fecal urgency liquid stools flatulence with discharge

oily spotting

Why Diets Often Fail

Require lot of time and energy

Cause feelings of deprivation

Donrsquot address why people overeat

Disrupt metabolism

Why SurgeryDiet and exercise are not effective

long term in the morbidly obese Surgery is an accepted and effective approach Medical co-morbidities are improvedresolved Increases life expectancy Decreases health care costs Surgical risk is acceptable vs risk of long-term obesity

RESOLUTION OF DISEASES FOLLOWING BARIATRIC SURGERY

Who Is a Surgical Candidate BMI gt 40 kgm2

-OR- BMI gt 35 kgm2 and major medical complications of

obesity-AND-

Failure of other approaches to long-term weight loss Age 18-55(relative)

Recommended BMI values for Bariatric Surgery in Asians

BMI ge 375

BMI ge 325 with two

associated co-

morbidities

No endocrine cause of obesity Acceptable operative risk Understands surgery and risks Absence of drug or alcohol problem No uncontrolled psychological conditions Consensus after bariatric team

evaluation SurgeonDieticianPsychologistConsultant

Dedicated to life-style change and follow-up

Obesity multidisciplinary team

Surgeon Physician Anesthetist Dietician Specialist bariatric nurse Skilled theatre staff Psychiatrist

Bariatric Surgery and Diabetes

International Diabetes Federation (2011) Journal of Diabetes (3(2011) 261-264) ldquoBariatric surgery is an appropriate treatment of people with T2D and

obesity who are not achieving recommended treatment targets with existing medical therapies especially in the presence of other major comorbiditiesrdquo

lt1 of those eligible actually have WLS for diabetes

Contraindications

Factors that may be considered contraindications include unstable CAD uncontrolled severe OSA uncontrolled psychiatric disorder mental retardation (IQ lt 60) inability to understand the surgery perceived inability to adhere to postoperative restrictions continued drug abuse malignancy with a poor 5-year survival prognosis Cirrhotic liver disease with portal hypertension

Preoperative EvaluationAttention should focus on issues unique to the obese patient

particularly cardiorespiratory status and the airwayConsideration of co morbidities ie hypertension diabetes heart

failure IHD obesity-hypoventilation syndrome metabolic syndrome etc

Results of the sleep study History of previous surgeries their anesthetic challenges need for

ICU admissionCurrent medicationsPatients scheduled for repeat bariatric surgery should be screened

preoperatively for long-term metabolic and nutritional abnormalities

Investigationshellip Recommended preoperative laboratory evaluations include

fasting blood glucose lipid profile electrolytes serum chemistries (to evaluate renal and hepatic function) complete blood count Serum ferritin vitamin B12 thyrotropin amp 25-hydroxyvitamin D

(Miller 7th edition- anesthesia for Bariatic Surgery) ABG measurements help evaluate ventilation as well as the need for perioperative oxygen administration and

postoperative ventilation Routine pulmonary function tests and liver function tests are not cost-effective in asymptomatic obese patients Coaugulation profile ( liver problem repeat surgery orlistat) ECG echocardiography Sleep study if suspected OSA

(Barash 6th edition anesthesia and obesity)

Concurrent Preoperative and Prophylactic Medications

Patients usual medications should be continued until the time of surgery with the possible exception of insulin and oral hypoglycemics

Antibiotic prophylaxis is usually indicated

Obesity itself does not increase the risk for aspiration acid aspiration prophylaxis including H2 receptor agonists or proton pump inhibitors must be considered in patients with identifiable risk for aspiration

Anxiolysis and prophylaxis against deep vein thrombosis (DVT) should be addressed at premedication

DVT consideration Morbid obesity is a major independent risk factor for sudden death from

acute postoperative pulmonary embolism Subcutaneous heparin 5000 IU administered before surgery and repeated every 8 to 12

hours until the patient is fully mobile reduces the risk of DVT LMWH can also be used

Preoperative prophylactic placement of an inferior vena cava filter should be considered in venous stasis disease BMI ge60 truncal obesity and OSA

What Are the Risks

MAJOR RISKS Death (1 of patients die within 30 days) Severe malnutrition (anemia PEM osteomalacia) Peritonitis (from leakage or ruptures at staple sites)

or other infection Obstructions caused by scar tissue in the stomach or

bowels

MINOR RISKS Dumping Syndrome (unpleasant but not harmful) Diarrhea and malodorous gas production Lactose intolerance Hair loss (short-term post-surgery) May have to eventually undergo surgical revision Pain post-surgery

History of Bariatric Surgery

Obesity surgery is not a new discipline The earliest Bariatric procedure performed was in 1954 at Minnesota The procedure

was Jejuno-ileal bypass In 1966Gastric Bypass was introduced as a surgical procedure for weight loss at the

University of Iowa In 1977Griffen reported the first Roux-en-Y Gastric Bypass In 1980surgeons with a more conservative approach developed the Vertical Banded

Gastroplasty Other procedures with longer intestinal segment bypass were also introduced such as

Biliopancreatic Diversions These complex procedures are recommended in super-obese patients ie BMIgt60

How does surgery work

RESTRICTIVE - RESTRICT AMOUNT OF FOOD INGESTED Decreases appetitehunger

Early satiety Behavior modification Gastric Banding (Lap Band)

Roux-en Y Gastric bypass (RYGB) Sleeve Gastrectomy

MALABSORPTIVE- LIMITS DIGESTION AND ABSORPTION Decreases length of intestine exposed to digested food

25 of fat is absorbed Behavior modification

Biliopancreatic Diversion Duodenal Switch (BPDDS)

ALL OPERATIONS CAN BE PERFORMED OPEN OR LAPAROSCOPICALLY

Laparoscopic vs Open

OPEN uarr post op pain Longer hospitalizations uarr wound complications

Infection Hernias Seromas

Return to work in 4-8 weeks

LAPAROSCOPIC darr post op pain Early mobility darr Wound complications 2-3 day hospital stay Return to work in 1-3 weeks

1 Nguyen NT et al Accelerated growth of bariatric surgery with the introduction of minimally invasive surgery Arch Surg 20051401198-202

Procedures that are solely restrictive by creating a small gastric pouch of volume 15 to 30 cc amp a degree of outlet obstruction leading to delayed gastric emptying The goal is to reduce oral intake by limiting gastric volume produce early satiety and leave the alimentary canal in continuity minimizing the risks of metabolic complications

1VERTICAL BANDED GASTROPLASTY

2ADJUSTABLE GASTRIC BANDING (LAGB )

3 SLEEVE GASTRECTOMY

4GASTRIC PLICATION

5 INTRA GASTRIC BALLOON (GASTRIC BALLOON)

RESTRICTIVE PROCEDURES

Malabsorption is achieved by creating a short gut syndrome andor by accomplishing distal mixing of bile and pancreatic juice with ingested nutrients thereby reducing absorption Some purely malabsorptive operations are no longer recommended due to their potential hazard to cause serious nutritional deficiencies

1 BILIOPANCREATIC DIVERSION2 THE JEJUNAL-ILEAL BYPASS3 ENDOLUMINAL SLEEVE

MALABSORPTIVE PROCEDURES

MIXED PROCEDURES

1GASTRIC BYPASS ROUX-EN-Y ( RYGBP)

2SLEEVE GASTRECTOMY WITH DUODENAL SWITCH

3IMPLANTABLE 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

The stomach is partitioned along its axis with a non-

adjustable poly-urethane band and with linear amp 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 was practiced in 1980

Vertical Banded Gastroplasty (VBG)

ADJUSTABLE GASTRIC BANDING (LAP BAND SURGERY LAGB)

Restrictive Procedure The procedure was first performed by Cadiere in 1992 but was made popular by Belachew and Legrand in 1993 An inflatable silicone BAND is placed around the top portion of the stomach to form a small stomach pouch amp sewed

This band is connected to a tube that leads to a port above the abdominal muscles placed below the skin (FILL ndash PORT)

During follow up visits we inject or remove saline solution to make the band tighter or looser

Adjustable Gastric Band

bull 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

How does the Band work

Surgery Factors Restriction of meal size Decreased appetite

Patient Factors Decreased calorie intake Increased calorie expenditure

LAP-BAND Adjustability

Unfilled Band Filled Band

Adjustments are made in the office

Complications of Gastric Lap-Band

bull Perforation of Stomachbull Slippagebull Gastric Erosion(much less after Pars flaccida technique) bull Dilated Esophagusbull Tubing access port problemsbull Mal positioningbull Abdominal Painbull Heartburnbull Vomitingbull Inability to Adjust the Bandbull Failure to Lose Weightbull Infection of Systembull Fatigue or malfunction

Advantages

No intestinal surgery No staplingcutting of stomach No nutritional risks Adjustable Reversible Safe

Foreign body Frequent follow-up visits Needs more commitment Easy to cheat

Disadvantages

Comparison of Adjustable Gastric Banding and Vertical Banded Gastroplasty

Laparoscopic adjustable gastric banding Reversible Adjustable Simpler to perform laparoscopically Sustained weight loss of gt50 EBW gt5

years following surgery Complications Gastric prolapse band

erosion rarely gastric perforation and access port complications

Vertical banded gastroplasty Irreversible Non adjustable Technically difficult by laparoscopy Weight loss of 25-50 EBW and weight gain

after 2-3 years Complications suture line disruption gastric

leak weight gain

>

>

Originally used as the first-stage operation for a proposed biliopancreatic diversion with duodenal switch in high-risk patients

The sleeve gastrectomy has caught on as a primary obesity treatment as surgeons are reporting weight loss of 55 of excess body weight past 5 years in some patients

The sleeve gastrectomy is also known as the greater curvature gastrectomy vertical or longitudinal gastrectomy or Pylorus preserving lsquogastric tube creationrsquo

Rapid and less traumatic operation Good resolution of co-morbidities and good weight loss

A further second surgical step is then easily feasible if necessary

SLEEVE GASTRECTOMY

SLEEVE GASTRECTOMY

A sleeve gastrectomy involves resection of

approximately 80 of the greater curvature

side of the stomach

Smaller tubular gastric ldquosleeverdquo created

along the lesser curve that is based on the

lesser curvature blood supply

Ideal approximate capacity of the stomach

after the procedure is about 30- 60 ml pouch

1MECHANICAL RESTRICTION by reducing the volume of the stomach and impairing stomach mobility Also called lsquoFood limitingrsquo operation

2HORMONAL MODIFICATION by removing a great part of the Ghrelin (Hunger Hormone) production tissue

(Ghrelin is a 28 amino-acid-peptide secreted by the oxyntic glands of the gastric fungus It is a potent orexigenic (appetite-stimulating) peptide mediated by the activation of its receptors in the hypothalamus or pituitary area)

The gastric fundus contains 10 to 20 times more ghrelin per one gram of tissue than the duodenum In the SG resection of the fundus removes the major portion of ghrelin release therefore appetite decreases

The sleeve gastrectomy (SG) induces weight loss by 2 mechanisms

>

Intragastric balloon involves placing a deflated balloon into the stomach and then filling it to decrease the amount of gastric space

The balloon can be left in the stomach for a maximum of 6 months and results in an average weight loss of 5ndash9 BMI over half a year

Done endoscopically

The intragastric balloon may be used prior to another bariatric surgery as a step-down procedure

INTRA GASTRIC BALLOON

>

>

The EndoBarrier gastrointestinal liner mimics the effects of gastric bypass surgery

Itrsquos designed to work by inserting a flexible

tube-like barrier into the duodenum amp 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

ENDO BARRIER LINER SYSTEM

B MAL- ABSORPTIVE PROCEDURES

Malabsorptive surgeries rearrange andor remove part of digestive system which then limits the amount of calories and nutrients that body can absorb Treatment with a large malabsorptive component results in the most weight loss but tend to have slightly higher complication rates

1JEJUNAL ILEAL BYPASS ndash no longer performed for high complication rates

2ILEAL TRANSPOSITION- New malabsoptive procedure on trial for treatment of DM type 2 and metabolic disorders

C COMBINATION PROCEDURES RESTRICTIVE + MALABSORBTIVE

1LAP GASTRIC BYPASS ndash ROUX-EN- Y ndash more malabsorption than the restrictive

2MINI- GASTRIC BYPASS- mainly restrictive

3DUODENAL SWITCH ndash the sleeve stomach is the restrictive portion ampthe intestinal bypass (duodenal switch) is the malabsorptive component

When surgery combines both restrictive and malabsorptive techniques it is know as a ldquocombinationrdquo procedure Most types of bariatric surgery carry at least a small element of both components but the following surgeries achieve a notable portion of weight loss from eachhellip

1 LAP GASTRIC BYPASS LGB

The Roux-en-Y gastric bypass(known simply as the LRYGBP) is the most commonly performed procedure

It primarily causesweight loss by restricting thefood intake however there ismore amount of mal absorption that occurs with this operation

GASTRIC BYPASS LRYGBP

bullThe stomach is stapled into2 pieces one small and one large The small piece becomes the ldquonewrdquo stomach pouch

bull The larger portion of the stomach stays in place however will lie dormant for the remainder of the patientrsquos life

GASTRIC BYPASS LGB

bull The small intestine (the jejunum) is divided using a surgical staplerApprox 50-70 cm from the DJ Junction

GASTRIC BYPASS LGB

Y- LIMB BP LIMB

bull The end of the Roux limb is then attached to the newly formed stomach pouch which carries food to the distal intestine

bull The Roux loop is completed by forming a jejunostomy

bull The Y limb or BPD limb carries digestive juices from the pancreas gall bladder liver and duodenum to the intestines

bull The food and the digestive juices mix where the Roux limb and Y limb meet much below say 100-150 cm from DJ

Roux limb or alimentary limb

100-150 cm

How Does the Roux-en-Y Work

Surgery factors restriction of meal size ldquodumping syndromerdquo some malabsorption decreased appetite

Patient factors calorie intake calorie expenditure

bull Most commonly performedbull Most reliable operation for long term weight lossbull Long term weight loss averages 60 to 75 percent of EBWbull Malnutrition is unusualbull Substantial improvement amp resolution in many co-morbid

obesity conditions

ADVANTAGES OF RYGBP

1 Not reversible

2 Mortality 05- 1

3 Perioperative complications 5-10

4 Stricture of gastrojejunostomy-10 (long term)

5 Long term risk of protein amp vitamin deficiency and marginal ulceration of GJA

6Long term risk of intestinal obstruction ndash 2

LAPAROSCOPIC GASTRIC BYPASSCOMPLICATIONS

Biliopancreatic Diversion (BPD)

Primarily malabsorptive but restrictive component also

First Terminal ileum is measured to a length of 50 cms marked with suture

The alimentary tract beyond the proximal part of stomach is rearranged to

include only distal 200 cm of ileum including common channel

Common channel-Distal 50 cm of terminal ileum for absorption of fat and

protein

The proximal end of ileum anastomosed to proximal end of stomach after

performing distal hemigastrectomy

Biliopancreatic Diversion with Duodenal Switch

Modification to lessen high incidence of vit b12 deficiency anastomotic stricture at gastrojejunal anastomosis

This procedure involves a sleeve gastrectomy that is then diverted at the duodenum into the ileum at a point measured proximally from the ileocecal valve (usually 250 cm)

The distal duodenum and jejunum the biliopancreatic limb are then anastomosed to the ileum at a point measured proximally from the ileocecal valve (usually 100 cm)

Common channel is 100cm Entire alimentary tract is 250 cm This is the most aggressive bypass procedure commonly offered today Major difference-Sleeve gastrectomy instead of distal hemigastrectomy

bull Most women regained normal menstrual function and most had documented

spontaneous ovulation

bull Significant improvement in hirsutism androgen profiles and about a 50 reduction in

HOMA-IR

bull Follow up for more than 2 years showed that all women resumed normal menstrual

cycles HbA1C decreased from 82 to 51 in lt 3 months

bull 78 saw improvement in metabolic syndrome amp 48 showed improvement in PCOS

2 ROLE OF BARIATRIC SURGERY IN PCOS PATIENTS

bull Decrease menstrual irregularities bull PCOS women have less hyper androgenism

bull Sex hormone binding globulin increases bull LH and FSH levels have been reported to increase

bull Ovulatory function measured by luteal LH and Progesterone secretion improved bull Leptin levels decrease reflecting improved reproductive metabolic status

bull Subclinical hypothyroidism significantly reduced

THE SAFE TIMING OF PREGNANCYoptimal or minimal time gt12 months after bariatric surgery before becoming pregnant in order to allow the rapid weight loss and metabolic changes to subside

4 BARIATRIC SURGERY IN REPRODUCTIVE WOMEN

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)

The foregut hypothesis theory ndash 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

Effect of Bariatric Surgery on Diabetes Mellitus

Combined Gastric Restriction amp Malabsorption

Operative Risks (vs cholecystectomy)

Perioperative Mortality 1-2 vs 02-08 Early Complications 10 vs 29Late Complications 20 vs 1-2

LimitationsWidening of (unbanded) gastrojejunostomyExpansion of gastric pouch 25 with nearly 100 weight regainAdaptation of limb that receives the food

SUMMARY OF ALL TYPES OF SURGERY

bull LRYGBP ndash worlds best procedure 60-70 WL dumping syndrome malnutrition

bull LAGB- low complications varying range of wt loss frequent post-op visits ( 10)

bull DSBPD- more wt loss high complications good for high BMI gt 50 malabsorption +

bull VBG(vertical band gastroplasty) ndash longest available results good wt loss improved co-morbidities right for some ptsrisks too high to justify rewards

bull SG- needs long term research 1st step procedure low risks higher wt loss lesser complications pouch could Stretch over time long staple line could cause problems in future frequency is accelerating because of technical ease 1st stage procedure before bypass

Post-surgical Complications

Anastomosis leaks or staple line leaks Pulmonary Embolism or DVT Cholelithiasis Stomal ulceration Dumping syndrome Constipation

Anastamosis Leaks

Up to 7-10 days after surgery Most common at gastrojejunostomy enteroenterostomy Roux

limb stump staple line Can lead to peritonitis sepsis possible death Presentation

Tachycardia tachypnea Fever Ab painback pain Pelvic pressure or rebound tenderness

Anastamosis Leaks

Order Gastrograffin upper GI series Subclinical cases

Bowel rest Parenteral nutrition IV antibiotic if H pylori

Clinically suspect leak Laparoscopic evaluation and leak repair

Failure to evaluate is the most common cause of preventable major long-term disability or death in bariatric surgical patients

Pulmonary Embolism

Sudden cause of death up to one month after surgery 20-30 mortality rate High risk may have vena cava filter placement prior to surgery Prophylaxis with compression stockings and LMWH Early ambulation imperitive

Pulmonary Embolism

Presentation Profound hypoxia Hypotension Signs of sepsis

Immediate spiral chest CT Abdominal exploration if too large for machine No pathology start anticoagulation Too largehelliphellipNO SURGERY

Cholelithiasis

Up to 36 of patients within 6 months post-op Bile stasis leads to increased sludge and gallstones Prophylactic cholecystectomy prior to surgery if

evidence of existing sludge or stones Prevent post-operative disease with concurrent bariatric

surgery and cholecystectomy Prophylactic use of urosidol

Expensive and unpalatable

Stomal Ulceration

12-15 within 2-4 mos Post-surgery Etiology

Overabundant acid in pouch leads to excessive acid passing through stoma

Pouch tension and staple line breakdown NSAID use

Presentation Dyspepsia vomiting Epigastric or retrosternal pain

Stomal Ulceration

Treatment PPI carafate Antibiotics if H Pylori Avoid NSAIDS alcohol smoking

If no response to treatment Endoscopy Back to surgery for pouch revision or staple line repair

Dumping Syndrome

More than 15 patients Hypotention Tachycardia Lightheadedness syncope Flushing Abdominal cramping and diarrhea Nausea and vomiting

Dumping Syndrome

Occurs with high dose simple sugar ingestion Sugar in small intestine causes osmotic overload and fluid

shift from blood to intestine Increased intestinal volume leads to watery diarrhea Decreased blood volume leads to systemic changes Patient education

Eat slowly Avoid drinking before during and not until 30 minutes after meals

Constipation

Most common complaint Causes

Dehydration and decreased fluid intake post-operatively Increased metabolic water needs Calcium and iron supplement use following surgery

Treat with increased fluids and stool softeners

Nutritional Consequences

Iron deficiency anemia B12 deficiency Folate deficiency Calcium and Vitamin D deficiency

Not seen with purely restrictive surgeries

Iron deficiency and anemia

Common following RYGB As high as 49 of patients Multifactorial cause

Low gastric acid levels prohibit iron cleavage from food Absorption inhibited because no nutrient exposure to duodenum or

proximal jejunum Decrease in iron-rich food consumption due to intolerance

Treat with oral supplementation of ferrous sulfate or ferrous gluconate

Vitamin B12 deficiency

Up to 70 of patients Lack of hydrochloric acid and pepsin in stomach

Prevents B12 cleavage from food Affects secretion of intrinsic factor thus B12 absorption

Intolerance to meat and milk Oral supplementation usually adequate otherwise IM injections used

Folate Deficiency

40 of gastric bypass patients Complete absorption requires B12 Absorption dependent on HCl and upper 13 stomach Deficiency generally caused by decreased consumption Oral supplementation

Vitamin D and Calcium Deficiency

Vitamin D deficiency is common among obese people Calcium absorption decreased because duodenum is

bypassed Intolerance to dairy foods high in calcium Vitamin D is required for Ca++ absorption Prolonged deficiencies lead to

Bone resorption osteomalacia osteoporosis Treat with calcium citrate supplementation and 2 weekly

doses of Vitamin D

Nutritional Implications of Various Bariatric Surgeries(34)

bull RYGB Malabsorption of Vit B12 Vit B1 (thiamin) Vit D Vit K Folate Iron Calcium

bull LAGB Folic Acid deficiency

bull BPD and BPDDS Vit A D E and K deficiency Protein-Calorie Malnutrition Malabsorption of

Calcium Zinc Selenium Sodium Potassium Chloride Phosphorus Magnesium

Recommended Daily Supplements(4)

Multivitamin with iron (prenatal vitamin will have adeq amount of folic acid)

Calcium (citrate) with vitamin D (1200-1500 mg calcium with 800-1000 IU vitamin D)

Oral vitamin B12 (500-1000 mcg) Iron (65 mgday in elemental form)

Vitamin C (to increase absorption of Iron) Thiamin (10 mgday)

Diet Recommendations(3)

Reduce food volume Chew food very well Slow pace of eating No liquids with meals Encourage fruits and vegetables as diet progresses Include high protein foods (at least 60gday) may need protein

supplements

Diet Progression Gastric Bypass

Stage 1 Clear liquids and protein supplement (1 week)

Stage 2No concentrated sweets low fat puree diet ( 3 weeks)

Stage 3 Regular texture weight reduction diet

Diet Progression Lap - Band

Stage 1 Clear liquids and protein supplement ( 2 weeks)

Stage 2 No concentrated sweets low fat puree diet (2weeks)

Stage 3 Regular texture weight reduction diet

Stage 1

Only clear liquids allowed Avoid sweetened beverages Sip very slowly No straws Avoid caffeinated carbonated and alcoholic beverages STOP drinking if you feel fullness pain or discomfort

Protein supplements

Begin the day after you go home from Hospital

Minimum protein target 70gmsday

May use powder or pre-mixed liquid forms (Whey protein is preferred)

Protein pills may not be used

Vitamin and Mineral Supplements

Gastric bypass patients In addition to eating much less food gastric bypass patients will also

absorb vitamins and minerals differently after surgery They will require daily multivitamin calcium and iron

supplementation for the rest of your life

Vitamin and Mineral Supplements

Lap-Bandreg patients

Require a multivitamin with minerals daily

It may be necessary to take additional vitamins and minerals eg calcium iron folateB1 B12These will be prescribed as needed

Stage 2 dietPUREE

Puree diet

Regular scheduled meals Avoid meal skipping Plan meals in advance Eat Slowly Eat protein foods first Moisten meats Use liquid protein as supplement not as meal replacement

Measure 2 oz portions at each meal eating when full Separate liquids and solids No bread rice or pasta Avoid added sugars and high fat

foods VARIETY

Indications for drug treatment

Pharmacological treatments are typically used as an adjunct to diet and exercise for patients with BMI of 30 or greater BMI of ge27 for patients with obesity-related risk factors or

comorbid diseases

Obesity Drugs Appetite suppressants

Noradrenergic (Schedule IV) Phentermine (Adipex Fastin) Diethylpropion (Tenuate)

Noradrenergic (Schedule III) Benzphetamine (Didrex) Phendimetrazine (Bontril)

Serotonergic Fenfluramine dexfenfluramine

Mixed Noradrenergic amp Serotonergic Sibutramine (Meridia)

Nutrient absorption reducers Lipase inhibitor

Orlistat (Xenical)

Sibutramine (Meridia)

Blocks presynaptic receptor uptake of norepinephrine and serotonin thereby potentiating their anorexic effect in the central nervous system

Contraindicated CAD CHF cardiac arrhythmias or stroke Side Effects hypertension arrhythmia tachycardia headache dry

mouth constipation insomnia

Orlistat

Inhibits pancreatic lipase and thereby reduces absorption of up to 30 of ingested dietary fat

Lipase inhibitor reduces fat absorption by ~30 resulting in reduction in energy intake

Inhibits digestion of dietary triglycerides decreases absorption of cholesterol and lipid-soluble vitamins

Side Effects

GI side effects due to inhibition of fat absorption pain fecal urgency liquid stools flatulence with discharge

oily spotting

Why Diets Often Fail

Require lot of time and energy

Cause feelings of deprivation

Donrsquot address why people overeat

Disrupt metabolism

Why SurgeryDiet and exercise are not effective

long term in the morbidly obese Surgery is an accepted and effective approach Medical co-morbidities are improvedresolved Increases life expectancy Decreases health care costs Surgical risk is acceptable vs risk of long-term obesity

RESOLUTION OF DISEASES FOLLOWING BARIATRIC SURGERY

Who Is a Surgical Candidate BMI gt 40 kgm2

-OR- BMI gt 35 kgm2 and major medical complications of

obesity-AND-

Failure of other approaches to long-term weight loss Age 18-55(relative)

Recommended BMI values for Bariatric Surgery in Asians

BMI ge 375

BMI ge 325 with two

associated co-

morbidities

No endocrine cause of obesity Acceptable operative risk Understands surgery and risks Absence of drug or alcohol problem No uncontrolled psychological conditions Consensus after bariatric team

evaluation SurgeonDieticianPsychologistConsultant

Dedicated to life-style change and follow-up

Obesity multidisciplinary team

Surgeon Physician Anesthetist Dietician Specialist bariatric nurse Skilled theatre staff Psychiatrist

Bariatric Surgery and Diabetes

International Diabetes Federation (2011) Journal of Diabetes (3(2011) 261-264) ldquoBariatric surgery is an appropriate treatment of people with T2D and

obesity who are not achieving recommended treatment targets with existing medical therapies especially in the presence of other major comorbiditiesrdquo

lt1 of those eligible actually have WLS for diabetes

Contraindications

Factors that may be considered contraindications include unstable CAD uncontrolled severe OSA uncontrolled psychiatric disorder mental retardation (IQ lt 60) inability to understand the surgery perceived inability to adhere to postoperative restrictions continued drug abuse malignancy with a poor 5-year survival prognosis Cirrhotic liver disease with portal hypertension

Preoperative EvaluationAttention should focus on issues unique to the obese patient

particularly cardiorespiratory status and the airwayConsideration of co morbidities ie hypertension diabetes heart

failure IHD obesity-hypoventilation syndrome metabolic syndrome etc

Results of the sleep study History of previous surgeries their anesthetic challenges need for

ICU admissionCurrent medicationsPatients scheduled for repeat bariatric surgery should be screened

preoperatively for long-term metabolic and nutritional abnormalities

Investigationshellip Recommended preoperative laboratory evaluations include

fasting blood glucose lipid profile electrolytes serum chemistries (to evaluate renal and hepatic function) complete blood count Serum ferritin vitamin B12 thyrotropin amp 25-hydroxyvitamin D

(Miller 7th edition- anesthesia for Bariatic Surgery) ABG measurements help evaluate ventilation as well as the need for perioperative oxygen administration and

postoperative ventilation Routine pulmonary function tests and liver function tests are not cost-effective in asymptomatic obese patients Coaugulation profile ( liver problem repeat surgery orlistat) ECG echocardiography Sleep study if suspected OSA

(Barash 6th edition anesthesia and obesity)

Concurrent Preoperative and Prophylactic Medications

Patients usual medications should be continued until the time of surgery with the possible exception of insulin and oral hypoglycemics

Antibiotic prophylaxis is usually indicated

Obesity itself does not increase the risk for aspiration acid aspiration prophylaxis including H2 receptor agonists or proton pump inhibitors must be considered in patients with identifiable risk for aspiration

Anxiolysis and prophylaxis against deep vein thrombosis (DVT) should be addressed at premedication

DVT consideration Morbid obesity is a major independent risk factor for sudden death from

acute postoperative pulmonary embolism Subcutaneous heparin 5000 IU administered before surgery and repeated every 8 to 12

hours until the patient is fully mobile reduces the risk of DVT LMWH can also be used

Preoperative prophylactic placement of an inferior vena cava filter should be considered in venous stasis disease BMI ge60 truncal obesity and OSA

What Are the Risks

MAJOR RISKS Death (1 of patients die within 30 days) Severe malnutrition (anemia PEM osteomalacia) Peritonitis (from leakage or ruptures at staple sites)

or other infection Obstructions caused by scar tissue in the stomach or

bowels

MINOR RISKS Dumping Syndrome (unpleasant but not harmful) Diarrhea and malodorous gas production Lactose intolerance Hair loss (short-term post-surgery) May have to eventually undergo surgical revision Pain post-surgery

History of Bariatric Surgery

Obesity surgery is not a new discipline The earliest Bariatric procedure performed was in 1954 at Minnesota The procedure

was Jejuno-ileal bypass In 1966Gastric Bypass was introduced as a surgical procedure for weight loss at the

University of Iowa In 1977Griffen reported the first Roux-en-Y Gastric Bypass In 1980surgeons with a more conservative approach developed the Vertical Banded

Gastroplasty Other procedures with longer intestinal segment bypass were also introduced such as

Biliopancreatic Diversions These complex procedures are recommended in super-obese patients ie BMIgt60

How does surgery work

RESTRICTIVE - RESTRICT AMOUNT OF FOOD INGESTED Decreases appetitehunger

Early satiety Behavior modification Gastric Banding (Lap Band)

Roux-en Y Gastric bypass (RYGB) Sleeve Gastrectomy

MALABSORPTIVE- LIMITS DIGESTION AND ABSORPTION Decreases length of intestine exposed to digested food

25 of fat is absorbed Behavior modification

Biliopancreatic Diversion Duodenal Switch (BPDDS)

ALL OPERATIONS CAN BE PERFORMED OPEN OR LAPAROSCOPICALLY

Laparoscopic vs Open

OPEN uarr post op pain Longer hospitalizations uarr wound complications

Infection Hernias Seromas

Return to work in 4-8 weeks

LAPAROSCOPIC darr post op pain Early mobility darr Wound complications 2-3 day hospital stay Return to work in 1-3 weeks

1 Nguyen NT et al Accelerated growth of bariatric surgery with the introduction of minimally invasive surgery Arch Surg 20051401198-202

Procedures that are solely restrictive by creating a small gastric pouch of volume 15 to 30 cc amp a degree of outlet obstruction leading to delayed gastric emptying The goal is to reduce oral intake by limiting gastric volume produce early satiety and leave the alimentary canal in continuity minimizing the risks of metabolic complications

1VERTICAL BANDED GASTROPLASTY

2ADJUSTABLE GASTRIC BANDING (LAGB )

3 SLEEVE GASTRECTOMY

4GASTRIC PLICATION

5 INTRA GASTRIC BALLOON (GASTRIC BALLOON)

RESTRICTIVE PROCEDURES

Malabsorption is achieved by creating a short gut syndrome andor by accomplishing distal mixing of bile and pancreatic juice with ingested nutrients thereby reducing absorption Some purely malabsorptive operations are no longer recommended due to their potential hazard to cause serious nutritional deficiencies

1 BILIOPANCREATIC DIVERSION2 THE JEJUNAL-ILEAL BYPASS3 ENDOLUMINAL SLEEVE

MALABSORPTIVE PROCEDURES

MIXED PROCEDURES

1GASTRIC BYPASS ROUX-EN-Y ( RYGBP)

2SLEEVE GASTRECTOMY WITH DUODENAL SWITCH

3IMPLANTABLE 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

The stomach is partitioned along its axis with a non-

adjustable poly-urethane band and with linear amp 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 was practiced in 1980

Vertical Banded Gastroplasty (VBG)

ADJUSTABLE GASTRIC BANDING (LAP BAND SURGERY LAGB)

Restrictive Procedure The procedure was first performed by Cadiere in 1992 but was made popular by Belachew and Legrand in 1993 An inflatable silicone BAND is placed around the top portion of the stomach to form a small stomach pouch amp sewed

This band is connected to a tube that leads to a port above the abdominal muscles placed below the skin (FILL ndash PORT)

During follow up visits we inject or remove saline solution to make the band tighter or looser

Adjustable Gastric Band

bull 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

How does the Band work

Surgery Factors Restriction of meal size Decreased appetite

Patient Factors Decreased calorie intake Increased calorie expenditure

LAP-BAND Adjustability

Unfilled Band Filled Band

Adjustments are made in the office

Complications of Gastric Lap-Band

bull Perforation of Stomachbull Slippagebull Gastric Erosion(much less after Pars flaccida technique) bull Dilated Esophagusbull Tubing access port problemsbull Mal positioningbull Abdominal Painbull Heartburnbull Vomitingbull Inability to Adjust the Bandbull Failure to Lose Weightbull Infection of Systembull Fatigue or malfunction

Advantages

No intestinal surgery No staplingcutting of stomach No nutritional risks Adjustable Reversible Safe

Foreign body Frequent follow-up visits Needs more commitment Easy to cheat

Disadvantages

Comparison of Adjustable Gastric Banding and Vertical Banded Gastroplasty

Laparoscopic adjustable gastric banding Reversible Adjustable Simpler to perform laparoscopically Sustained weight loss of gt50 EBW gt5

years following surgery Complications Gastric prolapse band

erosion rarely gastric perforation and access port complications

Vertical banded gastroplasty Irreversible Non adjustable Technically difficult by laparoscopy Weight loss of 25-50 EBW and weight gain

after 2-3 years Complications suture line disruption gastric

leak weight gain

>

>

Originally used as the first-stage operation for a proposed biliopancreatic diversion with duodenal switch in high-risk patients

The sleeve gastrectomy has caught on as a primary obesity treatment as surgeons are reporting weight loss of 55 of excess body weight past 5 years in some patients

The sleeve gastrectomy is also known as the greater curvature gastrectomy vertical or longitudinal gastrectomy or Pylorus preserving lsquogastric tube creationrsquo

Rapid and less traumatic operation Good resolution of co-morbidities and good weight loss

A further second surgical step is then easily feasible if necessary

SLEEVE GASTRECTOMY

SLEEVE GASTRECTOMY

A sleeve gastrectomy involves resection of

approximately 80 of the greater curvature

side of the stomach

Smaller tubular gastric ldquosleeverdquo created

along the lesser curve that is based on the

lesser curvature blood supply

Ideal approximate capacity of the stomach

after the procedure is about 30- 60 ml pouch

1MECHANICAL RESTRICTION by reducing the volume of the stomach and impairing stomach mobility Also called lsquoFood limitingrsquo operation

2HORMONAL MODIFICATION by removing a great part of the Ghrelin (Hunger Hormone) production tissue

(Ghrelin is a 28 amino-acid-peptide secreted by the oxyntic glands of the gastric fungus It is a potent orexigenic (appetite-stimulating) peptide mediated by the activation of its receptors in the hypothalamus or pituitary area)

The gastric fundus contains 10 to 20 times more ghrelin per one gram of tissue than the duodenum In the SG resection of the fundus removes the major portion of ghrelin release therefore appetite decreases

The sleeve gastrectomy (SG) induces weight loss by 2 mechanisms

>

Intragastric balloon involves placing a deflated balloon into the stomach and then filling it to decrease the amount of gastric space

The balloon can be left in the stomach for a maximum of 6 months and results in an average weight loss of 5ndash9 BMI over half a year

Done endoscopically

The intragastric balloon may be used prior to another bariatric surgery as a step-down procedure

INTRA GASTRIC BALLOON

>

>

The EndoBarrier gastrointestinal liner mimics the effects of gastric bypass surgery

Itrsquos designed to work by inserting a flexible

tube-like barrier into the duodenum amp 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

ENDO BARRIER LINER SYSTEM

B MAL- ABSORPTIVE PROCEDURES

Malabsorptive surgeries rearrange andor remove part of digestive system which then limits the amount of calories and nutrients that body can absorb Treatment with a large malabsorptive component results in the most weight loss but tend to have slightly higher complication rates

1JEJUNAL ILEAL BYPASS ndash no longer performed for high complication rates

2ILEAL TRANSPOSITION- New malabsoptive procedure on trial for treatment of DM type 2 and metabolic disorders

C COMBINATION PROCEDURES RESTRICTIVE + MALABSORBTIVE

1LAP GASTRIC BYPASS ndash ROUX-EN- Y ndash more malabsorption than the restrictive

2MINI- GASTRIC BYPASS- mainly restrictive

3DUODENAL SWITCH ndash the sleeve stomach is the restrictive portion ampthe intestinal bypass (duodenal switch) is the malabsorptive component

When surgery combines both restrictive and malabsorptive techniques it is know as a ldquocombinationrdquo procedure Most types of bariatric surgery carry at least a small element of both components but the following surgeries achieve a notable portion of weight loss from eachhellip

1 LAP GASTRIC BYPASS LGB

The Roux-en-Y gastric bypass(known simply as the LRYGBP) is the most commonly performed procedure

It primarily causesweight loss by restricting thefood intake however there ismore amount of mal absorption that occurs with this operation

GASTRIC BYPASS LRYGBP

bullThe stomach is stapled into2 pieces one small and one large The small piece becomes the ldquonewrdquo stomach pouch

bull The larger portion of the stomach stays in place however will lie dormant for the remainder of the patientrsquos life

GASTRIC BYPASS LGB

bull The small intestine (the jejunum) is divided using a surgical staplerApprox 50-70 cm from the DJ Junction

GASTRIC BYPASS LGB

Y- LIMB BP LIMB

bull The end of the Roux limb is then attached to the newly formed stomach pouch which carries food to the distal intestine

bull The Roux loop is completed by forming a jejunostomy

bull The Y limb or BPD limb carries digestive juices from the pancreas gall bladder liver and duodenum to the intestines

bull The food and the digestive juices mix where the Roux limb and Y limb meet much below say 100-150 cm from DJ

Roux limb or alimentary limb

100-150 cm

How Does the Roux-en-Y Work

Surgery factors restriction of meal size ldquodumping syndromerdquo some malabsorption decreased appetite

Patient factors calorie intake calorie expenditure

bull Most commonly performedbull Most reliable operation for long term weight lossbull Long term weight loss averages 60 to 75 percent of EBWbull Malnutrition is unusualbull Substantial improvement amp resolution in many co-morbid

obesity conditions

ADVANTAGES OF RYGBP

1 Not reversible

2 Mortality 05- 1

3 Perioperative complications 5-10

4 Stricture of gastrojejunostomy-10 (long term)

5 Long term risk of protein amp vitamin deficiency and marginal ulceration of GJA

6Long term risk of intestinal obstruction ndash 2

LAPAROSCOPIC GASTRIC BYPASSCOMPLICATIONS

Biliopancreatic Diversion (BPD)

Primarily malabsorptive but restrictive component also

First Terminal ileum is measured to a length of 50 cms marked with suture

The alimentary tract beyond the proximal part of stomach is rearranged to

include only distal 200 cm of ileum including common channel

Common channel-Distal 50 cm of terminal ileum for absorption of fat and

protein

The proximal end of ileum anastomosed to proximal end of stomach after

performing distal hemigastrectomy

Biliopancreatic Diversion with Duodenal Switch

Modification to lessen high incidence of vit b12 deficiency anastomotic stricture at gastrojejunal anastomosis

This procedure involves a sleeve gastrectomy that is then diverted at the duodenum into the ileum at a point measured proximally from the ileocecal valve (usually 250 cm)

The distal duodenum and jejunum the biliopancreatic limb are then anastomosed to the ileum at a point measured proximally from the ileocecal valve (usually 100 cm)

Common channel is 100cm Entire alimentary tract is 250 cm This is the most aggressive bypass procedure commonly offered today Major difference-Sleeve gastrectomy instead of distal hemigastrectomy

bull Most women regained normal menstrual function and most had documented

spontaneous ovulation

bull Significant improvement in hirsutism androgen profiles and about a 50 reduction in

HOMA-IR

bull Follow up for more than 2 years showed that all women resumed normal menstrual

cycles HbA1C decreased from 82 to 51 in lt 3 months

bull 78 saw improvement in metabolic syndrome amp 48 showed improvement in PCOS

2 ROLE OF BARIATRIC SURGERY IN PCOS PATIENTS

bull Decrease menstrual irregularities bull PCOS women have less hyper androgenism

bull Sex hormone binding globulin increases bull LH and FSH levels have been reported to increase

bull Ovulatory function measured by luteal LH and Progesterone secretion improved bull Leptin levels decrease reflecting improved reproductive metabolic status

bull Subclinical hypothyroidism significantly reduced

THE SAFE TIMING OF PREGNANCYoptimal or minimal time gt12 months after bariatric surgery before becoming pregnant in order to allow the rapid weight loss and metabolic changes to subside

4 BARIATRIC SURGERY IN REPRODUCTIVE WOMEN

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)

The foregut hypothesis theory ndash 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

Effect of Bariatric Surgery on Diabetes Mellitus

Combined Gastric Restriction amp Malabsorption

Operative Risks (vs cholecystectomy)

Perioperative Mortality 1-2 vs 02-08 Early Complications 10 vs 29Late Complications 20 vs 1-2

LimitationsWidening of (unbanded) gastrojejunostomyExpansion of gastric pouch 25 with nearly 100 weight regainAdaptation of limb that receives the food

SUMMARY OF ALL TYPES OF SURGERY

bull LRYGBP ndash worlds best procedure 60-70 WL dumping syndrome malnutrition

bull LAGB- low complications varying range of wt loss frequent post-op visits ( 10)

bull DSBPD- more wt loss high complications good for high BMI gt 50 malabsorption +

bull VBG(vertical band gastroplasty) ndash longest available results good wt loss improved co-morbidities right for some ptsrisks too high to justify rewards

bull SG- needs long term research 1st step procedure low risks higher wt loss lesser complications pouch could Stretch over time long staple line could cause problems in future frequency is accelerating because of technical ease 1st stage procedure before bypass

Post-surgical Complications

Anastomosis leaks or staple line leaks Pulmonary Embolism or DVT Cholelithiasis Stomal ulceration Dumping syndrome Constipation

Anastamosis Leaks

Up to 7-10 days after surgery Most common at gastrojejunostomy enteroenterostomy Roux

limb stump staple line Can lead to peritonitis sepsis possible death Presentation

Tachycardia tachypnea Fever Ab painback pain Pelvic pressure or rebound tenderness

Anastamosis Leaks

Order Gastrograffin upper GI series Subclinical cases

Bowel rest Parenteral nutrition IV antibiotic if H pylori

Clinically suspect leak Laparoscopic evaluation and leak repair

Failure to evaluate is the most common cause of preventable major long-term disability or death in bariatric surgical patients

Pulmonary Embolism

Sudden cause of death up to one month after surgery 20-30 mortality rate High risk may have vena cava filter placement prior to surgery Prophylaxis with compression stockings and LMWH Early ambulation imperitive

Pulmonary Embolism

Presentation Profound hypoxia Hypotension Signs of sepsis

Immediate spiral chest CT Abdominal exploration if too large for machine No pathology start anticoagulation Too largehelliphellipNO SURGERY

Cholelithiasis

Up to 36 of patients within 6 months post-op Bile stasis leads to increased sludge and gallstones Prophylactic cholecystectomy prior to surgery if

evidence of existing sludge or stones Prevent post-operative disease with concurrent bariatric

surgery and cholecystectomy Prophylactic use of urosidol

Expensive and unpalatable

Stomal Ulceration

12-15 within 2-4 mos Post-surgery Etiology

Overabundant acid in pouch leads to excessive acid passing through stoma

Pouch tension and staple line breakdown NSAID use

Presentation Dyspepsia vomiting Epigastric or retrosternal pain

Stomal Ulceration

Treatment PPI carafate Antibiotics if H Pylori Avoid NSAIDS alcohol smoking

If no response to treatment Endoscopy Back to surgery for pouch revision or staple line repair

Dumping Syndrome

More than 15 patients Hypotention Tachycardia Lightheadedness syncope Flushing Abdominal cramping and diarrhea Nausea and vomiting

Dumping Syndrome

Occurs with high dose simple sugar ingestion Sugar in small intestine causes osmotic overload and fluid

shift from blood to intestine Increased intestinal volume leads to watery diarrhea Decreased blood volume leads to systemic changes Patient education

Eat slowly Avoid drinking before during and not until 30 minutes after meals

Constipation

Most common complaint Causes

Dehydration and decreased fluid intake post-operatively Increased metabolic water needs Calcium and iron supplement use following surgery

Treat with increased fluids and stool softeners

Nutritional Consequences

Iron deficiency anemia B12 deficiency Folate deficiency Calcium and Vitamin D deficiency

Not seen with purely restrictive surgeries

Iron deficiency and anemia

Common following RYGB As high as 49 of patients Multifactorial cause

Low gastric acid levels prohibit iron cleavage from food Absorption inhibited because no nutrient exposure to duodenum or

proximal jejunum Decrease in iron-rich food consumption due to intolerance

Treat with oral supplementation of ferrous sulfate or ferrous gluconate

Vitamin B12 deficiency

Up to 70 of patients Lack of hydrochloric acid and pepsin in stomach

Prevents B12 cleavage from food Affects secretion of intrinsic factor thus B12 absorption

Intolerance to meat and milk Oral supplementation usually adequate otherwise IM injections used

Folate Deficiency

40 of gastric bypass patients Complete absorption requires B12 Absorption dependent on HCl and upper 13 stomach Deficiency generally caused by decreased consumption Oral supplementation

Vitamin D and Calcium Deficiency

Vitamin D deficiency is common among obese people Calcium absorption decreased because duodenum is

bypassed Intolerance to dairy foods high in calcium Vitamin D is required for Ca++ absorption Prolonged deficiencies lead to

Bone resorption osteomalacia osteoporosis Treat with calcium citrate supplementation and 2 weekly

doses of Vitamin D

Nutritional Implications of Various Bariatric Surgeries(34)

bull RYGB Malabsorption of Vit B12 Vit B1 (thiamin) Vit D Vit K Folate Iron Calcium

bull LAGB Folic Acid deficiency

bull BPD and BPDDS Vit A D E and K deficiency Protein-Calorie Malnutrition Malabsorption of

Calcium Zinc Selenium Sodium Potassium Chloride Phosphorus Magnesium

Recommended Daily Supplements(4)

Multivitamin with iron (prenatal vitamin will have adeq amount of folic acid)

Calcium (citrate) with vitamin D (1200-1500 mg calcium with 800-1000 IU vitamin D)

Oral vitamin B12 (500-1000 mcg) Iron (65 mgday in elemental form)

Vitamin C (to increase absorption of Iron) Thiamin (10 mgday)

Diet Recommendations(3)

Reduce food volume Chew food very well Slow pace of eating No liquids with meals Encourage fruits and vegetables as diet progresses Include high protein foods (at least 60gday) may need protein

supplements

Diet Progression Gastric Bypass

Stage 1 Clear liquids and protein supplement (1 week)

Stage 2No concentrated sweets low fat puree diet ( 3 weeks)

Stage 3 Regular texture weight reduction diet

Diet Progression Lap - Band

Stage 1 Clear liquids and protein supplement ( 2 weeks)

Stage 2 No concentrated sweets low fat puree diet (2weeks)

Stage 3 Regular texture weight reduction diet

Stage 1

Only clear liquids allowed Avoid sweetened beverages Sip very slowly No straws Avoid caffeinated carbonated and alcoholic beverages STOP drinking if you feel fullness pain or discomfort

Protein supplements

Begin the day after you go home from Hospital

Minimum protein target 70gmsday

May use powder or pre-mixed liquid forms (Whey protein is preferred)

Protein pills may not be used

Vitamin and Mineral Supplements

Gastric bypass patients In addition to eating much less food gastric bypass patients will also

absorb vitamins and minerals differently after surgery They will require daily multivitamin calcium and iron

supplementation for the rest of your life

Vitamin and Mineral Supplements

Lap-Bandreg patients

Require a multivitamin with minerals daily

It may be necessary to take additional vitamins and minerals eg calcium iron folateB1 B12These will be prescribed as needed

Stage 2 dietPUREE

Puree diet

Regular scheduled meals Avoid meal skipping Plan meals in advance Eat Slowly Eat protein foods first Moisten meats Use liquid protein as supplement not as meal replacement

Measure 2 oz portions at each meal eating when full Separate liquids and solids No bread rice or pasta Avoid added sugars and high fat

foods VARIETY

Obesity Drugs Appetite suppressants

Noradrenergic (Schedule IV) Phentermine (Adipex Fastin) Diethylpropion (Tenuate)

Noradrenergic (Schedule III) Benzphetamine (Didrex) Phendimetrazine (Bontril)

Serotonergic Fenfluramine dexfenfluramine

Mixed Noradrenergic amp Serotonergic Sibutramine (Meridia)

Nutrient absorption reducers Lipase inhibitor

Orlistat (Xenical)

Sibutramine (Meridia)

Blocks presynaptic receptor uptake of norepinephrine and serotonin thereby potentiating their anorexic effect in the central nervous system

Contraindicated CAD CHF cardiac arrhythmias or stroke Side Effects hypertension arrhythmia tachycardia headache dry

mouth constipation insomnia

Orlistat

Inhibits pancreatic lipase and thereby reduces absorption of up to 30 of ingested dietary fat

Lipase inhibitor reduces fat absorption by ~30 resulting in reduction in energy intake

Inhibits digestion of dietary triglycerides decreases absorption of cholesterol and lipid-soluble vitamins

Side Effects

GI side effects due to inhibition of fat absorption pain fecal urgency liquid stools flatulence with discharge

oily spotting

Why Diets Often Fail

Require lot of time and energy

Cause feelings of deprivation

Donrsquot address why people overeat

Disrupt metabolism

Why SurgeryDiet and exercise are not effective

long term in the morbidly obese Surgery is an accepted and effective approach Medical co-morbidities are improvedresolved Increases life expectancy Decreases health care costs Surgical risk is acceptable vs risk of long-term obesity

RESOLUTION OF DISEASES FOLLOWING BARIATRIC SURGERY

Who Is a Surgical Candidate BMI gt 40 kgm2

-OR- BMI gt 35 kgm2 and major medical complications of

obesity-AND-

Failure of other approaches to long-term weight loss Age 18-55(relative)

Recommended BMI values for Bariatric Surgery in Asians

BMI ge 375

BMI ge 325 with two

associated co-

morbidities

No endocrine cause of obesity Acceptable operative risk Understands surgery and risks Absence of drug or alcohol problem No uncontrolled psychological conditions Consensus after bariatric team

evaluation SurgeonDieticianPsychologistConsultant

Dedicated to life-style change and follow-up

Obesity multidisciplinary team

Surgeon Physician Anesthetist Dietician Specialist bariatric nurse Skilled theatre staff Psychiatrist

Bariatric Surgery and Diabetes

International Diabetes Federation (2011) Journal of Diabetes (3(2011) 261-264) ldquoBariatric surgery is an appropriate treatment of people with T2D and

obesity who are not achieving recommended treatment targets with existing medical therapies especially in the presence of other major comorbiditiesrdquo

lt1 of those eligible actually have WLS for diabetes

Contraindications

Factors that may be considered contraindications include unstable CAD uncontrolled severe OSA uncontrolled psychiatric disorder mental retardation (IQ lt 60) inability to understand the surgery perceived inability to adhere to postoperative restrictions continued drug abuse malignancy with a poor 5-year survival prognosis Cirrhotic liver disease with portal hypertension

Preoperative EvaluationAttention should focus on issues unique to the obese patient

particularly cardiorespiratory status and the airwayConsideration of co morbidities ie hypertension diabetes heart

failure IHD obesity-hypoventilation syndrome metabolic syndrome etc

Results of the sleep study History of previous surgeries their anesthetic challenges need for

ICU admissionCurrent medicationsPatients scheduled for repeat bariatric surgery should be screened

preoperatively for long-term metabolic and nutritional abnormalities

Investigationshellip Recommended preoperative laboratory evaluations include

fasting blood glucose lipid profile electrolytes serum chemistries (to evaluate renal and hepatic function) complete blood count Serum ferritin vitamin B12 thyrotropin amp 25-hydroxyvitamin D

(Miller 7th edition- anesthesia for Bariatic Surgery) ABG measurements help evaluate ventilation as well as the need for perioperative oxygen administration and

postoperative ventilation Routine pulmonary function tests and liver function tests are not cost-effective in asymptomatic obese patients Coaugulation profile ( liver problem repeat surgery orlistat) ECG echocardiography Sleep study if suspected OSA

(Barash 6th edition anesthesia and obesity)

Concurrent Preoperative and Prophylactic Medications

Patients usual medications should be continued until the time of surgery with the possible exception of insulin and oral hypoglycemics

Antibiotic prophylaxis is usually indicated

Obesity itself does not increase the risk for aspiration acid aspiration prophylaxis including H2 receptor agonists or proton pump inhibitors must be considered in patients with identifiable risk for aspiration

Anxiolysis and prophylaxis against deep vein thrombosis (DVT) should be addressed at premedication

DVT consideration Morbid obesity is a major independent risk factor for sudden death from

acute postoperative pulmonary embolism Subcutaneous heparin 5000 IU administered before surgery and repeated every 8 to 12

hours until the patient is fully mobile reduces the risk of DVT LMWH can also be used

Preoperative prophylactic placement of an inferior vena cava filter should be considered in venous stasis disease BMI ge60 truncal obesity and OSA

What Are the Risks

MAJOR RISKS Death (1 of patients die within 30 days) Severe malnutrition (anemia PEM osteomalacia) Peritonitis (from leakage or ruptures at staple sites)

or other infection Obstructions caused by scar tissue in the stomach or

bowels

MINOR RISKS Dumping Syndrome (unpleasant but not harmful) Diarrhea and malodorous gas production Lactose intolerance Hair loss (short-term post-surgery) May have to eventually undergo surgical revision Pain post-surgery

History of Bariatric Surgery

Obesity surgery is not a new discipline The earliest Bariatric procedure performed was in 1954 at Minnesota The procedure

was Jejuno-ileal bypass In 1966Gastric Bypass was introduced as a surgical procedure for weight loss at the

University of Iowa In 1977Griffen reported the first Roux-en-Y Gastric Bypass In 1980surgeons with a more conservative approach developed the Vertical Banded

Gastroplasty Other procedures with longer intestinal segment bypass were also introduced such as

Biliopancreatic Diversions These complex procedures are recommended in super-obese patients ie BMIgt60

How does surgery work

RESTRICTIVE - RESTRICT AMOUNT OF FOOD INGESTED Decreases appetitehunger

Early satiety Behavior modification Gastric Banding (Lap Band)

Roux-en Y Gastric bypass (RYGB) Sleeve Gastrectomy

MALABSORPTIVE- LIMITS DIGESTION AND ABSORPTION Decreases length of intestine exposed to digested food

25 of fat is absorbed Behavior modification

Biliopancreatic Diversion Duodenal Switch (BPDDS)

ALL OPERATIONS CAN BE PERFORMED OPEN OR LAPAROSCOPICALLY

Laparoscopic vs Open

OPEN uarr post op pain Longer hospitalizations uarr wound complications

Infection Hernias Seromas

Return to work in 4-8 weeks

LAPAROSCOPIC darr post op pain Early mobility darr Wound complications 2-3 day hospital stay Return to work in 1-3 weeks

1 Nguyen NT et al Accelerated growth of bariatric surgery with the introduction of minimally invasive surgery Arch Surg 20051401198-202

Procedures that are solely restrictive by creating a small gastric pouch of volume 15 to 30 cc amp a degree of outlet obstruction leading to delayed gastric emptying The goal is to reduce oral intake by limiting gastric volume produce early satiety and leave the alimentary canal in continuity minimizing the risks of metabolic complications

1VERTICAL BANDED GASTROPLASTY

2ADJUSTABLE GASTRIC BANDING (LAGB )

3 SLEEVE GASTRECTOMY

4GASTRIC PLICATION

5 INTRA GASTRIC BALLOON (GASTRIC BALLOON)

RESTRICTIVE PROCEDURES

Malabsorption is achieved by creating a short gut syndrome andor by accomplishing distal mixing of bile and pancreatic juice with ingested nutrients thereby reducing absorption Some purely malabsorptive operations are no longer recommended due to their potential hazard to cause serious nutritional deficiencies

1 BILIOPANCREATIC DIVERSION2 THE JEJUNAL-ILEAL BYPASS3 ENDOLUMINAL SLEEVE

MALABSORPTIVE PROCEDURES

MIXED PROCEDURES

1GASTRIC BYPASS ROUX-EN-Y ( RYGBP)

2SLEEVE GASTRECTOMY WITH DUODENAL SWITCH

3IMPLANTABLE 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

The stomach is partitioned along its axis with a non-

adjustable poly-urethane band and with linear amp 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 was practiced in 1980

Vertical Banded Gastroplasty (VBG)

ADJUSTABLE GASTRIC BANDING (LAP BAND SURGERY LAGB)

Restrictive Procedure The procedure was first performed by Cadiere in 1992 but was made popular by Belachew and Legrand in 1993 An inflatable silicone BAND is placed around the top portion of the stomach to form a small stomach pouch amp sewed

This band is connected to a tube that leads to a port above the abdominal muscles placed below the skin (FILL ndash PORT)

During follow up visits we inject or remove saline solution to make the band tighter or looser

Adjustable Gastric Band

bull 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

How does the Band work

Surgery Factors Restriction of meal size Decreased appetite

Patient Factors Decreased calorie intake Increased calorie expenditure

LAP-BAND Adjustability

Unfilled Band Filled Band

Adjustments are made in the office

Complications of Gastric Lap-Band

bull Perforation of Stomachbull Slippagebull Gastric Erosion(much less after Pars flaccida technique) bull Dilated Esophagusbull Tubing access port problemsbull Mal positioningbull Abdominal Painbull Heartburnbull Vomitingbull Inability to Adjust the Bandbull Failure to Lose Weightbull Infection of Systembull Fatigue or malfunction

Advantages

No intestinal surgery No staplingcutting of stomach No nutritional risks Adjustable Reversible Safe

Foreign body Frequent follow-up visits Needs more commitment Easy to cheat

Disadvantages

Comparison of Adjustable Gastric Banding and Vertical Banded Gastroplasty

Laparoscopic adjustable gastric banding Reversible Adjustable Simpler to perform laparoscopically Sustained weight loss of gt50 EBW gt5

years following surgery Complications Gastric prolapse band

erosion rarely gastric perforation and access port complications

Vertical banded gastroplasty Irreversible Non adjustable Technically difficult by laparoscopy Weight loss of 25-50 EBW and weight gain

after 2-3 years Complications suture line disruption gastric

leak weight gain

>

>

Originally used as the first-stage operation for a proposed biliopancreatic diversion with duodenal switch in high-risk patients

The sleeve gastrectomy has caught on as a primary obesity treatment as surgeons are reporting weight loss of 55 of excess body weight past 5 years in some patients

The sleeve gastrectomy is also known as the greater curvature gastrectomy vertical or longitudinal gastrectomy or Pylorus preserving lsquogastric tube creationrsquo

Rapid and less traumatic operation Good resolution of co-morbidities and good weight loss

A further second surgical step is then easily feasible if necessary

SLEEVE GASTRECTOMY

SLEEVE GASTRECTOMY

A sleeve gastrectomy involves resection of

approximately 80 of the greater curvature

side of the stomach

Smaller tubular gastric ldquosleeverdquo created

along the lesser curve that is based on the

lesser curvature blood supply

Ideal approximate capacity of the stomach

after the procedure is about 30- 60 ml pouch

1MECHANICAL RESTRICTION by reducing the volume of the stomach and impairing stomach mobility Also called lsquoFood limitingrsquo operation

2HORMONAL MODIFICATION by removing a great part of the Ghrelin (Hunger Hormone) production tissue

(Ghrelin is a 28 amino-acid-peptide secreted by the oxyntic glands of the gastric fungus It is a potent orexigenic (appetite-stimulating) peptide mediated by the activation of its receptors in the hypothalamus or pituitary area)

The gastric fundus contains 10 to 20 times more ghrelin per one gram of tissue than the duodenum In the SG resection of the fundus removes the major portion of ghrelin release therefore appetite decreases

The sleeve gastrectomy (SG) induces weight loss by 2 mechanisms

>

Intragastric balloon involves placing a deflated balloon into the stomach and then filling it to decrease the amount of gastric space

The balloon can be left in the stomach for a maximum of 6 months and results in an average weight loss of 5ndash9 BMI over half a year

Done endoscopically

The intragastric balloon may be used prior to another bariatric surgery as a step-down procedure

INTRA GASTRIC BALLOON

>

>

The EndoBarrier gastrointestinal liner mimics the effects of gastric bypass surgery

Itrsquos designed to work by inserting a flexible

tube-like barrier into the duodenum amp 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

ENDO BARRIER LINER SYSTEM

B MAL- ABSORPTIVE PROCEDURES

Malabsorptive surgeries rearrange andor remove part of digestive system which then limits the amount of calories and nutrients that body can absorb Treatment with a large malabsorptive component results in the most weight loss but tend to have slightly higher complication rates

1JEJUNAL ILEAL BYPASS ndash no longer performed for high complication rates

2ILEAL TRANSPOSITION- New malabsoptive procedure on trial for treatment of DM type 2 and metabolic disorders

C COMBINATION PROCEDURES RESTRICTIVE + MALABSORBTIVE

1LAP GASTRIC BYPASS ndash ROUX-EN- Y ndash more malabsorption than the restrictive

2MINI- GASTRIC BYPASS- mainly restrictive

3DUODENAL SWITCH ndash the sleeve stomach is the restrictive portion ampthe intestinal bypass (duodenal switch) is the malabsorptive component

When surgery combines both restrictive and malabsorptive techniques it is know as a ldquocombinationrdquo procedure Most types of bariatric surgery carry at least a small element of both components but the following surgeries achieve a notable portion of weight loss from eachhellip

1 LAP GASTRIC BYPASS LGB

The Roux-en-Y gastric bypass(known simply as the LRYGBP) is the most commonly performed procedure

It primarily causesweight loss by restricting thefood intake however there ismore amount of mal absorption that occurs with this operation

GASTRIC BYPASS LRYGBP

bullThe stomach is stapled into2 pieces one small and one large The small piece becomes the ldquonewrdquo stomach pouch

bull The larger portion of the stomach stays in place however will lie dormant for the remainder of the patientrsquos life

GASTRIC BYPASS LGB

bull The small intestine (the jejunum) is divided using a surgical staplerApprox 50-70 cm from the DJ Junction

GASTRIC BYPASS LGB

Y- LIMB BP LIMB

bull The end of the Roux limb is then attached to the newly formed stomach pouch which carries food to the distal intestine

bull The Roux loop is completed by forming a jejunostomy

bull The Y limb or BPD limb carries digestive juices from the pancreas gall bladder liver and duodenum to the intestines

bull The food and the digestive juices mix where the Roux limb and Y limb meet much below say 100-150 cm from DJ

Roux limb or alimentary limb

100-150 cm

How Does the Roux-en-Y Work

Surgery factors restriction of meal size ldquodumping syndromerdquo some malabsorption decreased appetite

Patient factors calorie intake calorie expenditure

bull Most commonly performedbull Most reliable operation for long term weight lossbull Long term weight loss averages 60 to 75 percent of EBWbull Malnutrition is unusualbull Substantial improvement amp resolution in many co-morbid

obesity conditions

ADVANTAGES OF RYGBP

1 Not reversible

2 Mortality 05- 1

3 Perioperative complications 5-10

4 Stricture of gastrojejunostomy-10 (long term)

5 Long term risk of protein amp vitamin deficiency and marginal ulceration of GJA

6Long term risk of intestinal obstruction ndash 2

LAPAROSCOPIC GASTRIC BYPASSCOMPLICATIONS

Biliopancreatic Diversion (BPD)

Primarily malabsorptive but restrictive component also

First Terminal ileum is measured to a length of 50 cms marked with suture

The alimentary tract beyond the proximal part of stomach is rearranged to

include only distal 200 cm of ileum including common channel

Common channel-Distal 50 cm of terminal ileum for absorption of fat and

protein

The proximal end of ileum anastomosed to proximal end of stomach after

performing distal hemigastrectomy

Biliopancreatic Diversion with Duodenal Switch

Modification to lessen high incidence of vit b12 deficiency anastomotic stricture at gastrojejunal anastomosis

This procedure involves a sleeve gastrectomy that is then diverted at the duodenum into the ileum at a point measured proximally from the ileocecal valve (usually 250 cm)

The distal duodenum and jejunum the biliopancreatic limb are then anastomosed to the ileum at a point measured proximally from the ileocecal valve (usually 100 cm)

Common channel is 100cm Entire alimentary tract is 250 cm This is the most aggressive bypass procedure commonly offered today Major difference-Sleeve gastrectomy instead of distal hemigastrectomy

bull Most women regained normal menstrual function and most had documented

spontaneous ovulation

bull Significant improvement in hirsutism androgen profiles and about a 50 reduction in

HOMA-IR

bull Follow up for more than 2 years showed that all women resumed normal menstrual

cycles HbA1C decreased from 82 to 51 in lt 3 months

bull 78 saw improvement in metabolic syndrome amp 48 showed improvement in PCOS

2 ROLE OF BARIATRIC SURGERY IN PCOS PATIENTS

bull Decrease menstrual irregularities bull PCOS women have less hyper androgenism

bull Sex hormone binding globulin increases bull LH and FSH levels have been reported to increase

bull Ovulatory function measured by luteal LH and Progesterone secretion improved bull Leptin levels decrease reflecting improved reproductive metabolic status

bull Subclinical hypothyroidism significantly reduced

THE SAFE TIMING OF PREGNANCYoptimal or minimal time gt12 months after bariatric surgery before becoming pregnant in order to allow the rapid weight loss and metabolic changes to subside

4 BARIATRIC SURGERY IN REPRODUCTIVE WOMEN

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)

The foregut hypothesis theory ndash 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

Effect of Bariatric Surgery on Diabetes Mellitus

Combined Gastric Restriction amp Malabsorption

Operative Risks (vs cholecystectomy)

Perioperative Mortality 1-2 vs 02-08 Early Complications 10 vs 29Late Complications 20 vs 1-2

LimitationsWidening of (unbanded) gastrojejunostomyExpansion of gastric pouch 25 with nearly 100 weight regainAdaptation of limb that receives the food

SUMMARY OF ALL TYPES OF SURGERY

bull LRYGBP ndash worlds best procedure 60-70 WL dumping syndrome malnutrition

bull LAGB- low complications varying range of wt loss frequent post-op visits ( 10)

bull DSBPD- more wt loss high complications good for high BMI gt 50 malabsorption +

bull VBG(vertical band gastroplasty) ndash longest available results good wt loss improved co-morbidities right for some ptsrisks too high to justify rewards

bull SG- needs long term research 1st step procedure low risks higher wt loss lesser complications pouch could Stretch over time long staple line could cause problems in future frequency is accelerating because of technical ease 1st stage procedure before bypass

Post-surgical Complications

Anastomosis leaks or staple line leaks Pulmonary Embolism or DVT Cholelithiasis Stomal ulceration Dumping syndrome Constipation

Anastamosis Leaks

Up to 7-10 days after surgery Most common at gastrojejunostomy enteroenterostomy Roux

limb stump staple line Can lead to peritonitis sepsis possible death Presentation

Tachycardia tachypnea Fever Ab painback pain Pelvic pressure or rebound tenderness

Anastamosis Leaks

Order Gastrograffin upper GI series Subclinical cases

Bowel rest Parenteral nutrition IV antibiotic if H pylori

Clinically suspect leak Laparoscopic evaluation and leak repair

Failure to evaluate is the most common cause of preventable major long-term disability or death in bariatric surgical patients

Pulmonary Embolism

Sudden cause of death up to one month after surgery 20-30 mortality rate High risk may have vena cava filter placement prior to surgery Prophylaxis with compression stockings and LMWH Early ambulation imperitive

Pulmonary Embolism

Presentation Profound hypoxia Hypotension Signs of sepsis

Immediate spiral chest CT Abdominal exploration if too large for machine No pathology start anticoagulation Too largehelliphellipNO SURGERY

Cholelithiasis

Up to 36 of patients within 6 months post-op Bile stasis leads to increased sludge and gallstones Prophylactic cholecystectomy prior to surgery if

evidence of existing sludge or stones Prevent post-operative disease with concurrent bariatric

surgery and cholecystectomy Prophylactic use of urosidol

Expensive and unpalatable

Stomal Ulceration

12-15 within 2-4 mos Post-surgery Etiology

Overabundant acid in pouch leads to excessive acid passing through stoma

Pouch tension and staple line breakdown NSAID use

Presentation Dyspepsia vomiting Epigastric or retrosternal pain

Stomal Ulceration

Treatment PPI carafate Antibiotics if H Pylori Avoid NSAIDS alcohol smoking

If no response to treatment Endoscopy Back to surgery for pouch revision or staple line repair

Dumping Syndrome

More than 15 patients Hypotention Tachycardia Lightheadedness syncope Flushing Abdominal cramping and diarrhea Nausea and vomiting

Dumping Syndrome

Occurs with high dose simple sugar ingestion Sugar in small intestine causes osmotic overload and fluid

shift from blood to intestine Increased intestinal volume leads to watery diarrhea Decreased blood volume leads to systemic changes Patient education

Eat slowly Avoid drinking before during and not until 30 minutes after meals

Constipation

Most common complaint Causes

Dehydration and decreased fluid intake post-operatively Increased metabolic water needs Calcium and iron supplement use following surgery

Treat with increased fluids and stool softeners

Nutritional Consequences

Iron deficiency anemia B12 deficiency Folate deficiency Calcium and Vitamin D deficiency

Not seen with purely restrictive surgeries

Iron deficiency and anemia

Common following RYGB As high as 49 of patients Multifactorial cause

Low gastric acid levels prohibit iron cleavage from food Absorption inhibited because no nutrient exposure to duodenum or

proximal jejunum Decrease in iron-rich food consumption due to intolerance

Treat with oral supplementation of ferrous sulfate or ferrous gluconate

Vitamin B12 deficiency

Up to 70 of patients Lack of hydrochloric acid and pepsin in stomach

Prevents B12 cleavage from food Affects secretion of intrinsic factor thus B12 absorption

Intolerance to meat and milk Oral supplementation usually adequate otherwise IM injections used

Folate Deficiency

40 of gastric bypass patients Complete absorption requires B12 Absorption dependent on HCl and upper 13 stomach Deficiency generally caused by decreased consumption Oral supplementation

Vitamin D and Calcium Deficiency

Vitamin D deficiency is common among obese people Calcium absorption decreased because duodenum is

bypassed Intolerance to dairy foods high in calcium Vitamin D is required for Ca++ absorption Prolonged deficiencies lead to

Bone resorption osteomalacia osteoporosis Treat with calcium citrate supplementation and 2 weekly

doses of Vitamin D

Nutritional Implications of Various Bariatric Surgeries(34)

bull RYGB Malabsorption of Vit B12 Vit B1 (thiamin) Vit D Vit K Folate Iron Calcium

bull LAGB Folic Acid deficiency

bull BPD and BPDDS Vit A D E and K deficiency Protein-Calorie Malnutrition Malabsorption of

Calcium Zinc Selenium Sodium Potassium Chloride Phosphorus Magnesium

Recommended Daily Supplements(4)

Multivitamin with iron (prenatal vitamin will have adeq amount of folic acid)

Calcium (citrate) with vitamin D (1200-1500 mg calcium with 800-1000 IU vitamin D)

Oral vitamin B12 (500-1000 mcg) Iron (65 mgday in elemental form)

Vitamin C (to increase absorption of Iron) Thiamin (10 mgday)

Diet Recommendations(3)

Reduce food volume Chew food very well Slow pace of eating No liquids with meals Encourage fruits and vegetables as diet progresses Include high protein foods (at least 60gday) may need protein

supplements

Diet Progression Gastric Bypass

Stage 1 Clear liquids and protein supplement (1 week)

Stage 2No concentrated sweets low fat puree diet ( 3 weeks)

Stage 3 Regular texture weight reduction diet

Diet Progression Lap - Band

Stage 1 Clear liquids and protein supplement ( 2 weeks)

Stage 2 No concentrated sweets low fat puree diet (2weeks)

Stage 3 Regular texture weight reduction diet

Stage 1

Only clear liquids allowed Avoid sweetened beverages Sip very slowly No straws Avoid caffeinated carbonated and alcoholic beverages STOP drinking if you feel fullness pain or discomfort

Protein supplements

Begin the day after you go home from Hospital

Minimum protein target 70gmsday

May use powder or pre-mixed liquid forms (Whey protein is preferred)

Protein pills may not be used

Vitamin and Mineral Supplements

Gastric bypass patients In addition to eating much less food gastric bypass patients will also

absorb vitamins and minerals differently after surgery They will require daily multivitamin calcium and iron

supplementation for the rest of your life

Vitamin and Mineral Supplements

Lap-Bandreg patients

Require a multivitamin with minerals daily

It may be necessary to take additional vitamins and minerals eg calcium iron folateB1 B12These will be prescribed as needed

Stage 2 dietPUREE

Puree diet

Regular scheduled meals Avoid meal skipping Plan meals in advance Eat Slowly Eat protein foods first Moisten meats Use liquid protein as supplement not as meal replacement

Measure 2 oz portions at each meal eating when full Separate liquids and solids No bread rice or pasta Avoid added sugars and high fat

foods VARIETY

Sibutramine (Meridia)

Blocks presynaptic receptor uptake of norepinephrine and serotonin thereby potentiating their anorexic effect in the central nervous system

Contraindicated CAD CHF cardiac arrhythmias or stroke Side Effects hypertension arrhythmia tachycardia headache dry

mouth constipation insomnia

Orlistat

Inhibits pancreatic lipase and thereby reduces absorption of up to 30 of ingested dietary fat

Lipase inhibitor reduces fat absorption by ~30 resulting in reduction in energy intake

Inhibits digestion of dietary triglycerides decreases absorption of cholesterol and lipid-soluble vitamins

Side Effects

GI side effects due to inhibition of fat absorption pain fecal urgency liquid stools flatulence with discharge

oily spotting

Why Diets Often Fail

Require lot of time and energy

Cause feelings of deprivation

Donrsquot address why people overeat

Disrupt metabolism

Why SurgeryDiet and exercise are not effective

long term in the morbidly obese Surgery is an accepted and effective approach Medical co-morbidities are improvedresolved Increases life expectancy Decreases health care costs Surgical risk is acceptable vs risk of long-term obesity

RESOLUTION OF DISEASES FOLLOWING BARIATRIC SURGERY

Who Is a Surgical Candidate BMI gt 40 kgm2

-OR- BMI gt 35 kgm2 and major medical complications of

obesity-AND-

Failure of other approaches to long-term weight loss Age 18-55(relative)

Recommended BMI values for Bariatric Surgery in Asians

BMI ge 375

BMI ge 325 with two

associated co-

morbidities

No endocrine cause of obesity Acceptable operative risk Understands surgery and risks Absence of drug or alcohol problem No uncontrolled psychological conditions Consensus after bariatric team

evaluation SurgeonDieticianPsychologistConsultant

Dedicated to life-style change and follow-up

Obesity multidisciplinary team

Surgeon Physician Anesthetist Dietician Specialist bariatric nurse Skilled theatre staff Psychiatrist

Bariatric Surgery and Diabetes

International Diabetes Federation (2011) Journal of Diabetes (3(2011) 261-264) ldquoBariatric surgery is an appropriate treatment of people with T2D and

obesity who are not achieving recommended treatment targets with existing medical therapies especially in the presence of other major comorbiditiesrdquo

lt1 of those eligible actually have WLS for diabetes

Contraindications

Factors that may be considered contraindications include unstable CAD uncontrolled severe OSA uncontrolled psychiatric disorder mental retardation (IQ lt 60) inability to understand the surgery perceived inability to adhere to postoperative restrictions continued drug abuse malignancy with a poor 5-year survival prognosis Cirrhotic liver disease with portal hypertension

Preoperative EvaluationAttention should focus on issues unique to the obese patient

particularly cardiorespiratory status and the airwayConsideration of co morbidities ie hypertension diabetes heart

failure IHD obesity-hypoventilation syndrome metabolic syndrome etc

Results of the sleep study History of previous surgeries their anesthetic challenges need for

ICU admissionCurrent medicationsPatients scheduled for repeat bariatric surgery should be screened

preoperatively for long-term metabolic and nutritional abnormalities

Investigationshellip Recommended preoperative laboratory evaluations include

fasting blood glucose lipid profile electrolytes serum chemistries (to evaluate renal and hepatic function) complete blood count Serum ferritin vitamin B12 thyrotropin amp 25-hydroxyvitamin D

(Miller 7th edition- anesthesia for Bariatic Surgery) ABG measurements help evaluate ventilation as well as the need for perioperative oxygen administration and

postoperative ventilation Routine pulmonary function tests and liver function tests are not cost-effective in asymptomatic obese patients Coaugulation profile ( liver problem repeat surgery orlistat) ECG echocardiography Sleep study if suspected OSA

(Barash 6th edition anesthesia and obesity)

Concurrent Preoperative and Prophylactic Medications

Patients usual medications should be continued until the time of surgery with the possible exception of insulin and oral hypoglycemics

Antibiotic prophylaxis is usually indicated

Obesity itself does not increase the risk for aspiration acid aspiration prophylaxis including H2 receptor agonists or proton pump inhibitors must be considered in patients with identifiable risk for aspiration

Anxiolysis and prophylaxis against deep vein thrombosis (DVT) should be addressed at premedication

DVT consideration Morbid obesity is a major independent risk factor for sudden death from

acute postoperative pulmonary embolism Subcutaneous heparin 5000 IU administered before surgery and repeated every 8 to 12

hours until the patient is fully mobile reduces the risk of DVT LMWH can also be used

Preoperative prophylactic placement of an inferior vena cava filter should be considered in venous stasis disease BMI ge60 truncal obesity and OSA

What Are the Risks

MAJOR RISKS Death (1 of patients die within 30 days) Severe malnutrition (anemia PEM osteomalacia) Peritonitis (from leakage or ruptures at staple sites)

or other infection Obstructions caused by scar tissue in the stomach or

bowels

MINOR RISKS Dumping Syndrome (unpleasant but not harmful) Diarrhea and malodorous gas production Lactose intolerance Hair loss (short-term post-surgery) May have to eventually undergo surgical revision Pain post-surgery

History of Bariatric Surgery

Obesity surgery is not a new discipline The earliest Bariatric procedure performed was in 1954 at Minnesota The procedure

was Jejuno-ileal bypass In 1966Gastric Bypass was introduced as a surgical procedure for weight loss at the

University of Iowa In 1977Griffen reported the first Roux-en-Y Gastric Bypass In 1980surgeons with a more conservative approach developed the Vertical Banded

Gastroplasty Other procedures with longer intestinal segment bypass were also introduced such as

Biliopancreatic Diversions These complex procedures are recommended in super-obese patients ie BMIgt60

How does surgery work

RESTRICTIVE - RESTRICT AMOUNT OF FOOD INGESTED Decreases appetitehunger

Early satiety Behavior modification Gastric Banding (Lap Band)

Roux-en Y Gastric bypass (RYGB) Sleeve Gastrectomy

MALABSORPTIVE- LIMITS DIGESTION AND ABSORPTION Decreases length of intestine exposed to digested food

25 of fat is absorbed Behavior modification

Biliopancreatic Diversion Duodenal Switch (BPDDS)

ALL OPERATIONS CAN BE PERFORMED OPEN OR LAPAROSCOPICALLY

Laparoscopic vs Open

OPEN uarr post op pain Longer hospitalizations uarr wound complications

Infection Hernias Seromas

Return to work in 4-8 weeks

LAPAROSCOPIC darr post op pain Early mobility darr Wound complications 2-3 day hospital stay Return to work in 1-3 weeks

1 Nguyen NT et al Accelerated growth of bariatric surgery with the introduction of minimally invasive surgery Arch Surg 20051401198-202

Procedures that are solely restrictive by creating a small gastric pouch of volume 15 to 30 cc amp a degree of outlet obstruction leading to delayed gastric emptying The goal is to reduce oral intake by limiting gastric volume produce early satiety and leave the alimentary canal in continuity minimizing the risks of metabolic complications

1VERTICAL BANDED GASTROPLASTY

2ADJUSTABLE GASTRIC BANDING (LAGB )

3 SLEEVE GASTRECTOMY

4GASTRIC PLICATION

5 INTRA GASTRIC BALLOON (GASTRIC BALLOON)

RESTRICTIVE PROCEDURES

Malabsorption is achieved by creating a short gut syndrome andor by accomplishing distal mixing of bile and pancreatic juice with ingested nutrients thereby reducing absorption Some purely malabsorptive operations are no longer recommended due to their potential hazard to cause serious nutritional deficiencies

1 BILIOPANCREATIC DIVERSION2 THE JEJUNAL-ILEAL BYPASS3 ENDOLUMINAL SLEEVE

MALABSORPTIVE PROCEDURES

MIXED PROCEDURES

1GASTRIC BYPASS ROUX-EN-Y ( RYGBP)

2SLEEVE GASTRECTOMY WITH DUODENAL SWITCH

3IMPLANTABLE 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

The stomach is partitioned along its axis with a non-

adjustable poly-urethane band and with linear amp 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 was practiced in 1980

Vertical Banded Gastroplasty (VBG)

ADJUSTABLE GASTRIC BANDING (LAP BAND SURGERY LAGB)

Restrictive Procedure The procedure was first performed by Cadiere in 1992 but was made popular by Belachew and Legrand in 1993 An inflatable silicone BAND is placed around the top portion of the stomach to form a small stomach pouch amp sewed

This band is connected to a tube that leads to a port above the abdominal muscles placed below the skin (FILL ndash PORT)

During follow up visits we inject or remove saline solution to make the band tighter or looser

Adjustable Gastric Band

bull 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

How does the Band work

Surgery Factors Restriction of meal size Decreased appetite

Patient Factors Decreased calorie intake Increased calorie expenditure

LAP-BAND Adjustability

Unfilled Band Filled Band

Adjustments are made in the office

Complications of Gastric Lap-Band

bull Perforation of Stomachbull Slippagebull Gastric Erosion(much less after Pars flaccida technique) bull Dilated Esophagusbull Tubing access port problemsbull Mal positioningbull Abdominal Painbull Heartburnbull Vomitingbull Inability to Adjust the Bandbull Failure to Lose Weightbull Infection of Systembull Fatigue or malfunction

Advantages

No intestinal surgery No staplingcutting of stomach No nutritional risks Adjustable Reversible Safe

Foreign body Frequent follow-up visits Needs more commitment Easy to cheat

Disadvantages

Comparison of Adjustable Gastric Banding and Vertical Banded Gastroplasty

Laparoscopic adjustable gastric banding Reversible Adjustable Simpler to perform laparoscopically Sustained weight loss of gt50 EBW gt5

years following surgery Complications Gastric prolapse band

erosion rarely gastric perforation and access port complications

Vertical banded gastroplasty Irreversible Non adjustable Technically difficult by laparoscopy Weight loss of 25-50 EBW and weight gain

after 2-3 years Complications suture line disruption gastric

leak weight gain

>

>

Originally used as the first-stage operation for a proposed biliopancreatic diversion with duodenal switch in high-risk patients

The sleeve gastrectomy has caught on as a primary obesity treatment as surgeons are reporting weight loss of 55 of excess body weight past 5 years in some patients

The sleeve gastrectomy is also known as the greater curvature gastrectomy vertical or longitudinal gastrectomy or Pylorus preserving lsquogastric tube creationrsquo

Rapid and less traumatic operation Good resolution of co-morbidities and good weight loss

A further second surgical step is then easily feasible if necessary

SLEEVE GASTRECTOMY

SLEEVE GASTRECTOMY

A sleeve gastrectomy involves resection of

approximately 80 of the greater curvature

side of the stomach

Smaller tubular gastric ldquosleeverdquo created

along the lesser curve that is based on the

lesser curvature blood supply

Ideal approximate capacity of the stomach

after the procedure is about 30- 60 ml pouch

1MECHANICAL RESTRICTION by reducing the volume of the stomach and impairing stomach mobility Also called lsquoFood limitingrsquo operation

2HORMONAL MODIFICATION by removing a great part of the Ghrelin (Hunger Hormone) production tissue

(Ghrelin is a 28 amino-acid-peptide secreted by the oxyntic glands of the gastric fungus It is a potent orexigenic (appetite-stimulating) peptide mediated by the activation of its receptors in the hypothalamus or pituitary area)

The gastric fundus contains 10 to 20 times more ghrelin per one gram of tissue than the duodenum In the SG resection of the fundus removes the major portion of ghrelin release therefore appetite decreases

The sleeve gastrectomy (SG) induces weight loss by 2 mechanisms

>

Intragastric balloon involves placing a deflated balloon into the stomach and then filling it to decrease the amount of gastric space

The balloon can be left in the stomach for a maximum of 6 months and results in an average weight loss of 5ndash9 BMI over half a year

Done endoscopically

The intragastric balloon may be used prior to another bariatric surgery as a step-down procedure

INTRA GASTRIC BALLOON

>

>

The EndoBarrier gastrointestinal liner mimics the effects of gastric bypass surgery

Itrsquos designed to work by inserting a flexible

tube-like barrier into the duodenum amp 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

ENDO BARRIER LINER SYSTEM

B MAL- ABSORPTIVE PROCEDURES

Malabsorptive surgeries rearrange andor remove part of digestive system which then limits the amount of calories and nutrients that body can absorb Treatment with a large malabsorptive component results in the most weight loss but tend to have slightly higher complication rates

1JEJUNAL ILEAL BYPASS ndash no longer performed for high complication rates

2ILEAL TRANSPOSITION- New malabsoptive procedure on trial for treatment of DM type 2 and metabolic disorders

C COMBINATION PROCEDURES RESTRICTIVE + MALABSORBTIVE

1LAP GASTRIC BYPASS ndash ROUX-EN- Y ndash more malabsorption than the restrictive

2MINI- GASTRIC BYPASS- mainly restrictive

3DUODENAL SWITCH ndash the sleeve stomach is the restrictive portion ampthe intestinal bypass (duodenal switch) is the malabsorptive component

When surgery combines both restrictive and malabsorptive techniques it is know as a ldquocombinationrdquo procedure Most types of bariatric surgery carry at least a small element of both components but the following surgeries achieve a notable portion of weight loss from eachhellip

1 LAP GASTRIC BYPASS LGB

The Roux-en-Y gastric bypass(known simply as the LRYGBP) is the most commonly performed procedure

It primarily causesweight loss by restricting thefood intake however there ismore amount of mal absorption that occurs with this operation

GASTRIC BYPASS LRYGBP

bullThe stomach is stapled into2 pieces one small and one large The small piece becomes the ldquonewrdquo stomach pouch

bull The larger portion of the stomach stays in place however will lie dormant for the remainder of the patientrsquos life

GASTRIC BYPASS LGB

bull The small intestine (the jejunum) is divided using a surgical staplerApprox 50-70 cm from the DJ Junction

GASTRIC BYPASS LGB

Y- LIMB BP LIMB

bull The end of the Roux limb is then attached to the newly formed stomach pouch which carries food to the distal intestine

bull The Roux loop is completed by forming a jejunostomy

bull The Y limb or BPD limb carries digestive juices from the pancreas gall bladder liver and duodenum to the intestines

bull The food and the digestive juices mix where the Roux limb and Y limb meet much below say 100-150 cm from DJ

Roux limb or alimentary limb

100-150 cm

How Does the Roux-en-Y Work

Surgery factors restriction of meal size ldquodumping syndromerdquo some malabsorption decreased appetite

Patient factors calorie intake calorie expenditure

bull Most commonly performedbull Most reliable operation for long term weight lossbull Long term weight loss averages 60 to 75 percent of EBWbull Malnutrition is unusualbull Substantial improvement amp resolution in many co-morbid

obesity conditions

ADVANTAGES OF RYGBP

1 Not reversible

2 Mortality 05- 1

3 Perioperative complications 5-10

4 Stricture of gastrojejunostomy-10 (long term)

5 Long term risk of protein amp vitamin deficiency and marginal ulceration of GJA

6Long term risk of intestinal obstruction ndash 2

LAPAROSCOPIC GASTRIC BYPASSCOMPLICATIONS

Biliopancreatic Diversion (BPD)

Primarily malabsorptive but restrictive component also

First Terminal ileum is measured to a length of 50 cms marked with suture

The alimentary tract beyond the proximal part of stomach is rearranged to

include only distal 200 cm of ileum including common channel

Common channel-Distal 50 cm of terminal ileum for absorption of fat and

protein

The proximal end of ileum anastomosed to proximal end of stomach after

performing distal hemigastrectomy

Biliopancreatic Diversion with Duodenal Switch

Modification to lessen high incidence of vit b12 deficiency anastomotic stricture at gastrojejunal anastomosis

This procedure involves a sleeve gastrectomy that is then diverted at the duodenum into the ileum at a point measured proximally from the ileocecal valve (usually 250 cm)

The distal duodenum and jejunum the biliopancreatic limb are then anastomosed to the ileum at a point measured proximally from the ileocecal valve (usually 100 cm)

Common channel is 100cm Entire alimentary tract is 250 cm This is the most aggressive bypass procedure commonly offered today Major difference-Sleeve gastrectomy instead of distal hemigastrectomy

bull Most women regained normal menstrual function and most had documented

spontaneous ovulation

bull Significant improvement in hirsutism androgen profiles and about a 50 reduction in

HOMA-IR

bull Follow up for more than 2 years showed that all women resumed normal menstrual

cycles HbA1C decreased from 82 to 51 in lt 3 months

bull 78 saw improvement in metabolic syndrome amp 48 showed improvement in PCOS

2 ROLE OF BARIATRIC SURGERY IN PCOS PATIENTS

bull Decrease menstrual irregularities bull PCOS women have less hyper androgenism

bull Sex hormone binding globulin increases bull LH and FSH levels have been reported to increase

bull Ovulatory function measured by luteal LH and Progesterone secretion improved bull Leptin levels decrease reflecting improved reproductive metabolic status

bull Subclinical hypothyroidism significantly reduced

THE SAFE TIMING OF PREGNANCYoptimal or minimal time gt12 months after bariatric surgery before becoming pregnant in order to allow the rapid weight loss and metabolic changes to subside

4 BARIATRIC SURGERY IN REPRODUCTIVE WOMEN

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)

The foregut hypothesis theory ndash 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

Effect of Bariatric Surgery on Diabetes Mellitus

Combined Gastric Restriction amp Malabsorption

Operative Risks (vs cholecystectomy)

Perioperative Mortality 1-2 vs 02-08 Early Complications 10 vs 29Late Complications 20 vs 1-2

LimitationsWidening of (unbanded) gastrojejunostomyExpansion of gastric pouch 25 with nearly 100 weight regainAdaptation of limb that receives the food

SUMMARY OF ALL TYPES OF SURGERY

bull LRYGBP ndash worlds best procedure 60-70 WL dumping syndrome malnutrition

bull LAGB- low complications varying range of wt loss frequent post-op visits ( 10)

bull DSBPD- more wt loss high complications good for high BMI gt 50 malabsorption +

bull VBG(vertical band gastroplasty) ndash longest available results good wt loss improved co-morbidities right for some ptsrisks too high to justify rewards

bull SG- needs long term research 1st step procedure low risks higher wt loss lesser complications pouch could Stretch over time long staple line could cause problems in future frequency is accelerating because of technical ease 1st stage procedure before bypass

Post-surgical Complications

Anastomosis leaks or staple line leaks Pulmonary Embolism or DVT Cholelithiasis Stomal ulceration Dumping syndrome Constipation

Anastamosis Leaks

Up to 7-10 days after surgery Most common at gastrojejunostomy enteroenterostomy Roux

limb stump staple line Can lead to peritonitis sepsis possible death Presentation

Tachycardia tachypnea Fever Ab painback pain Pelvic pressure or rebound tenderness

Anastamosis Leaks

Order Gastrograffin upper GI series Subclinical cases

Bowel rest Parenteral nutrition IV antibiotic if H pylori

Clinically suspect leak Laparoscopic evaluation and leak repair

Failure to evaluate is the most common cause of preventable major long-term disability or death in bariatric surgical patients

Pulmonary Embolism

Sudden cause of death up to one month after surgery 20-30 mortality rate High risk may have vena cava filter placement prior to surgery Prophylaxis with compression stockings and LMWH Early ambulation imperitive

Pulmonary Embolism

Presentation Profound hypoxia Hypotension Signs of sepsis

Immediate spiral chest CT Abdominal exploration if too large for machine No pathology start anticoagulation Too largehelliphellipNO SURGERY

Cholelithiasis

Up to 36 of patients within 6 months post-op Bile stasis leads to increased sludge and gallstones Prophylactic cholecystectomy prior to surgery if

evidence of existing sludge or stones Prevent post-operative disease with concurrent bariatric

surgery and cholecystectomy Prophylactic use of urosidol

Expensive and unpalatable

Stomal Ulceration

12-15 within 2-4 mos Post-surgery Etiology

Overabundant acid in pouch leads to excessive acid passing through stoma

Pouch tension and staple line breakdown NSAID use

Presentation Dyspepsia vomiting Epigastric or retrosternal pain

Stomal Ulceration

Treatment PPI carafate Antibiotics if H Pylori Avoid NSAIDS alcohol smoking

If no response to treatment Endoscopy Back to surgery for pouch revision or staple line repair

Dumping Syndrome

More than 15 patients Hypotention Tachycardia Lightheadedness syncope Flushing Abdominal cramping and diarrhea Nausea and vomiting

Dumping Syndrome

Occurs with high dose simple sugar ingestion Sugar in small intestine causes osmotic overload and fluid

shift from blood to intestine Increased intestinal volume leads to watery diarrhea Decreased blood volume leads to systemic changes Patient education

Eat slowly Avoid drinking before during and not until 30 minutes after meals

Constipation

Most common complaint Causes

Dehydration and decreased fluid intake post-operatively Increased metabolic water needs Calcium and iron supplement use following surgery

Treat with increased fluids and stool softeners

Nutritional Consequences

Iron deficiency anemia B12 deficiency Folate deficiency Calcium and Vitamin D deficiency

Not seen with purely restrictive surgeries

Iron deficiency and anemia

Common following RYGB As high as 49 of patients Multifactorial cause

Low gastric acid levels prohibit iron cleavage from food Absorption inhibited because no nutrient exposure to duodenum or

proximal jejunum Decrease in iron-rich food consumption due to intolerance

Treat with oral supplementation of ferrous sulfate or ferrous gluconate

Vitamin B12 deficiency

Up to 70 of patients Lack of hydrochloric acid and pepsin in stomach

Prevents B12 cleavage from food Affects secretion of intrinsic factor thus B12 absorption

Intolerance to meat and milk Oral supplementation usually adequate otherwise IM injections used

Folate Deficiency

40 of gastric bypass patients Complete absorption requires B12 Absorption dependent on HCl and upper 13 stomach Deficiency generally caused by decreased consumption Oral supplementation

Vitamin D and Calcium Deficiency

Vitamin D deficiency is common among obese people Calcium absorption decreased because duodenum is

bypassed Intolerance to dairy foods high in calcium Vitamin D is required for Ca++ absorption Prolonged deficiencies lead to

Bone resorption osteomalacia osteoporosis Treat with calcium citrate supplementation and 2 weekly

doses of Vitamin D

Nutritional Implications of Various Bariatric Surgeries(34)

bull RYGB Malabsorption of Vit B12 Vit B1 (thiamin) Vit D Vit K Folate Iron Calcium

bull LAGB Folic Acid deficiency

bull BPD and BPDDS Vit A D E and K deficiency Protein-Calorie Malnutrition Malabsorption of

Calcium Zinc Selenium Sodium Potassium Chloride Phosphorus Magnesium

Recommended Daily Supplements(4)

Multivitamin with iron (prenatal vitamin will have adeq amount of folic acid)

Calcium (citrate) with vitamin D (1200-1500 mg calcium with 800-1000 IU vitamin D)

Oral vitamin B12 (500-1000 mcg) Iron (65 mgday in elemental form)

Vitamin C (to increase absorption of Iron) Thiamin (10 mgday)

Diet Recommendations(3)

Reduce food volume Chew food very well Slow pace of eating No liquids with meals Encourage fruits and vegetables as diet progresses Include high protein foods (at least 60gday) may need protein

supplements

Diet Progression Gastric Bypass

Stage 1 Clear liquids and protein supplement (1 week)

Stage 2No concentrated sweets low fat puree diet ( 3 weeks)

Stage 3 Regular texture weight reduction diet

Diet Progression Lap - Band

Stage 1 Clear liquids and protein supplement ( 2 weeks)

Stage 2 No concentrated sweets low fat puree diet (2weeks)

Stage 3 Regular texture weight reduction diet

Stage 1

Only clear liquids allowed Avoid sweetened beverages Sip very slowly No straws Avoid caffeinated carbonated and alcoholic beverages STOP drinking if you feel fullness pain or discomfort

Protein supplements

Begin the day after you go home from Hospital

Minimum protein target 70gmsday

May use powder or pre-mixed liquid forms (Whey protein is preferred)

Protein pills may not be used

Vitamin and Mineral Supplements

Gastric bypass patients In addition to eating much less food gastric bypass patients will also

absorb vitamins and minerals differently after surgery They will require daily multivitamin calcium and iron

supplementation for the rest of your life

Vitamin and Mineral Supplements

Lap-Bandreg patients

Require a multivitamin with minerals daily

It may be necessary to take additional vitamins and minerals eg calcium iron folateB1 B12These will be prescribed as needed

Stage 2 dietPUREE

Puree diet

Regular scheduled meals Avoid meal skipping Plan meals in advance Eat Slowly Eat protein foods first Moisten meats Use liquid protein as supplement not as meal replacement

Measure 2 oz portions at each meal eating when full Separate liquids and solids No bread rice or pasta Avoid added sugars and high fat

foods VARIETY

Orlistat

Inhibits pancreatic lipase and thereby reduces absorption of up to 30 of ingested dietary fat

Lipase inhibitor reduces fat absorption by ~30 resulting in reduction in energy intake

Inhibits digestion of dietary triglycerides decreases absorption of cholesterol and lipid-soluble vitamins

Side Effects

GI side effects due to inhibition of fat absorption pain fecal urgency liquid stools flatulence with discharge

oily spotting

Why Diets Often Fail

Require lot of time and energy

Cause feelings of deprivation

Donrsquot address why people overeat

Disrupt metabolism

Why SurgeryDiet and exercise are not effective

long term in the morbidly obese Surgery is an accepted and effective approach Medical co-morbidities are improvedresolved Increases life expectancy Decreases health care costs Surgical risk is acceptable vs risk of long-term obesity

RESOLUTION OF DISEASES FOLLOWING BARIATRIC SURGERY

Who Is a Surgical Candidate BMI gt 40 kgm2

-OR- BMI gt 35 kgm2 and major medical complications of

obesity-AND-

Failure of other approaches to long-term weight loss Age 18-55(relative)

Recommended BMI values for Bariatric Surgery in Asians

BMI ge 375

BMI ge 325 with two

associated co-

morbidities

No endocrine cause of obesity Acceptable operative risk Understands surgery and risks Absence of drug or alcohol problem No uncontrolled psychological conditions Consensus after bariatric team

evaluation SurgeonDieticianPsychologistConsultant

Dedicated to life-style change and follow-up

Obesity multidisciplinary team

Surgeon Physician Anesthetist Dietician Specialist bariatric nurse Skilled theatre staff Psychiatrist

Bariatric Surgery and Diabetes

International Diabetes Federation (2011) Journal of Diabetes (3(2011) 261-264) ldquoBariatric surgery is an appropriate treatment of people with T2D and

obesity who are not achieving recommended treatment targets with existing medical therapies especially in the presence of other major comorbiditiesrdquo

lt1 of those eligible actually have WLS for diabetes

Contraindications

Factors that may be considered contraindications include unstable CAD uncontrolled severe OSA uncontrolled psychiatric disorder mental retardation (IQ lt 60) inability to understand the surgery perceived inability to adhere to postoperative restrictions continued drug abuse malignancy with a poor 5-year survival prognosis Cirrhotic liver disease with portal hypertension

Preoperative EvaluationAttention should focus on issues unique to the obese patient

particularly cardiorespiratory status and the airwayConsideration of co morbidities ie hypertension diabetes heart

failure IHD obesity-hypoventilation syndrome metabolic syndrome etc

Results of the sleep study History of previous surgeries their anesthetic challenges need for

ICU admissionCurrent medicationsPatients scheduled for repeat bariatric surgery should be screened

preoperatively for long-term metabolic and nutritional abnormalities

Investigationshellip Recommended preoperative laboratory evaluations include

fasting blood glucose lipid profile electrolytes serum chemistries (to evaluate renal and hepatic function) complete blood count Serum ferritin vitamin B12 thyrotropin amp 25-hydroxyvitamin D

(Miller 7th edition- anesthesia for Bariatic Surgery) ABG measurements help evaluate ventilation as well as the need for perioperative oxygen administration and

postoperative ventilation Routine pulmonary function tests and liver function tests are not cost-effective in asymptomatic obese patients Coaugulation profile ( liver problem repeat surgery orlistat) ECG echocardiography Sleep study if suspected OSA

(Barash 6th edition anesthesia and obesity)

Concurrent Preoperative and Prophylactic Medications

Patients usual medications should be continued until the time of surgery with the possible exception of insulin and oral hypoglycemics

Antibiotic prophylaxis is usually indicated

Obesity itself does not increase the risk for aspiration acid aspiration prophylaxis including H2 receptor agonists or proton pump inhibitors must be considered in patients with identifiable risk for aspiration

Anxiolysis and prophylaxis against deep vein thrombosis (DVT) should be addressed at premedication

DVT consideration Morbid obesity is a major independent risk factor for sudden death from

acute postoperative pulmonary embolism Subcutaneous heparin 5000 IU administered before surgery and repeated every 8 to 12

hours until the patient is fully mobile reduces the risk of DVT LMWH can also be used

Preoperative prophylactic placement of an inferior vena cava filter should be considered in venous stasis disease BMI ge60 truncal obesity and OSA

What Are the Risks

MAJOR RISKS Death (1 of patients die within 30 days) Severe malnutrition (anemia PEM osteomalacia) Peritonitis (from leakage or ruptures at staple sites)

or other infection Obstructions caused by scar tissue in the stomach or

bowels

MINOR RISKS Dumping Syndrome (unpleasant but not harmful) Diarrhea and malodorous gas production Lactose intolerance Hair loss (short-term post-surgery) May have to eventually undergo surgical revision Pain post-surgery

History of Bariatric Surgery

Obesity surgery is not a new discipline The earliest Bariatric procedure performed was in 1954 at Minnesota The procedure

was Jejuno-ileal bypass In 1966Gastric Bypass was introduced as a surgical procedure for weight loss at the

University of Iowa In 1977Griffen reported the first Roux-en-Y Gastric Bypass In 1980surgeons with a more conservative approach developed the Vertical Banded

Gastroplasty Other procedures with longer intestinal segment bypass were also introduced such as

Biliopancreatic Diversions These complex procedures are recommended in super-obese patients ie BMIgt60

How does surgery work

RESTRICTIVE - RESTRICT AMOUNT OF FOOD INGESTED Decreases appetitehunger

Early satiety Behavior modification Gastric Banding (Lap Band)

Roux-en Y Gastric bypass (RYGB) Sleeve Gastrectomy

MALABSORPTIVE- LIMITS DIGESTION AND ABSORPTION Decreases length of intestine exposed to digested food

25 of fat is absorbed Behavior modification

Biliopancreatic Diversion Duodenal Switch (BPDDS)

ALL OPERATIONS CAN BE PERFORMED OPEN OR LAPAROSCOPICALLY

Laparoscopic vs Open

OPEN uarr post op pain Longer hospitalizations uarr wound complications

Infection Hernias Seromas

Return to work in 4-8 weeks

LAPAROSCOPIC darr post op pain Early mobility darr Wound complications 2-3 day hospital stay Return to work in 1-3 weeks

1 Nguyen NT et al Accelerated growth of bariatric surgery with the introduction of minimally invasive surgery Arch Surg 20051401198-202

Procedures that are solely restrictive by creating a small gastric pouch of volume 15 to 30 cc amp a degree of outlet obstruction leading to delayed gastric emptying The goal is to reduce oral intake by limiting gastric volume produce early satiety and leave the alimentary canal in continuity minimizing the risks of metabolic complications

1VERTICAL BANDED GASTROPLASTY

2ADJUSTABLE GASTRIC BANDING (LAGB )

3 SLEEVE GASTRECTOMY

4GASTRIC PLICATION

5 INTRA GASTRIC BALLOON (GASTRIC BALLOON)

RESTRICTIVE PROCEDURES

Malabsorption is achieved by creating a short gut syndrome andor by accomplishing distal mixing of bile and pancreatic juice with ingested nutrients thereby reducing absorption Some purely malabsorptive operations are no longer recommended due to their potential hazard to cause serious nutritional deficiencies

1 BILIOPANCREATIC DIVERSION2 THE JEJUNAL-ILEAL BYPASS3 ENDOLUMINAL SLEEVE

MALABSORPTIVE PROCEDURES

MIXED PROCEDURES

1GASTRIC BYPASS ROUX-EN-Y ( RYGBP)

2SLEEVE GASTRECTOMY WITH DUODENAL SWITCH

3IMPLANTABLE 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

The stomach is partitioned along its axis with a non-

adjustable poly-urethane band and with linear amp 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 was practiced in 1980

Vertical Banded Gastroplasty (VBG)

ADJUSTABLE GASTRIC BANDING (LAP BAND SURGERY LAGB)

Restrictive Procedure The procedure was first performed by Cadiere in 1992 but was made popular by Belachew and Legrand in 1993 An inflatable silicone BAND is placed around the top portion of the stomach to form a small stomach pouch amp sewed

This band is connected to a tube that leads to a port above the abdominal muscles placed below the skin (FILL ndash PORT)

During follow up visits we inject or remove saline solution to make the band tighter or looser

Adjustable Gastric Band

bull 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

How does the Band work

Surgery Factors Restriction of meal size Decreased appetite

Patient Factors Decreased calorie intake Increased calorie expenditure

LAP-BAND Adjustability

Unfilled Band Filled Band

Adjustments are made in the office

Complications of Gastric Lap-Band

bull Perforation of Stomachbull Slippagebull Gastric Erosion(much less after Pars flaccida technique) bull Dilated Esophagusbull Tubing access port problemsbull Mal positioningbull Abdominal Painbull Heartburnbull Vomitingbull Inability to Adjust the Bandbull Failure to Lose Weightbull Infection of Systembull Fatigue or malfunction

Advantages

No intestinal surgery No staplingcutting of stomach No nutritional risks Adjustable Reversible Safe

Foreign body Frequent follow-up visits Needs more commitment Easy to cheat

Disadvantages

Comparison of Adjustable Gastric Banding and Vertical Banded Gastroplasty

Laparoscopic adjustable gastric banding Reversible Adjustable Simpler to perform laparoscopically Sustained weight loss of gt50 EBW gt5

years following surgery Complications Gastric prolapse band

erosion rarely gastric perforation and access port complications

Vertical banded gastroplasty Irreversible Non adjustable Technically difficult by laparoscopy Weight loss of 25-50 EBW and weight gain

after 2-3 years Complications suture line disruption gastric

leak weight gain

>

>

Originally used as the first-stage operation for a proposed biliopancreatic diversion with duodenal switch in high-risk patients

The sleeve gastrectomy has caught on as a primary obesity treatment as surgeons are reporting weight loss of 55 of excess body weight past 5 years in some patients

The sleeve gastrectomy is also known as the greater curvature gastrectomy vertical or longitudinal gastrectomy or Pylorus preserving lsquogastric tube creationrsquo

Rapid and less traumatic operation Good resolution of co-morbidities and good weight loss

A further second surgical step is then easily feasible if necessary

SLEEVE GASTRECTOMY

SLEEVE GASTRECTOMY

A sleeve gastrectomy involves resection of

approximately 80 of the greater curvature

side of the stomach

Smaller tubular gastric ldquosleeverdquo created

along the lesser curve that is based on the

lesser curvature blood supply

Ideal approximate capacity of the stomach

after the procedure is about 30- 60 ml pouch

1MECHANICAL RESTRICTION by reducing the volume of the stomach and impairing stomach mobility Also called lsquoFood limitingrsquo operation

2HORMONAL MODIFICATION by removing a great part of the Ghrelin (Hunger Hormone) production tissue

(Ghrelin is a 28 amino-acid-peptide secreted by the oxyntic glands of the gastric fungus It is a potent orexigenic (appetite-stimulating) peptide mediated by the activation of its receptors in the hypothalamus or pituitary area)

The gastric fundus contains 10 to 20 times more ghrelin per one gram of tissue than the duodenum In the SG resection of the fundus removes the major portion of ghrelin release therefore appetite decreases

The sleeve gastrectomy (SG) induces weight loss by 2 mechanisms

>

Intragastric balloon involves placing a deflated balloon into the stomach and then filling it to decrease the amount of gastric space

The balloon can be left in the stomach for a maximum of 6 months and results in an average weight loss of 5ndash9 BMI over half a year

Done endoscopically

The intragastric balloon may be used prior to another bariatric surgery as a step-down procedure

INTRA GASTRIC BALLOON

>

>

The EndoBarrier gastrointestinal liner mimics the effects of gastric bypass surgery

Itrsquos designed to work by inserting a flexible

tube-like barrier into the duodenum amp 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

ENDO BARRIER LINER SYSTEM

B MAL- ABSORPTIVE PROCEDURES

Malabsorptive surgeries rearrange andor remove part of digestive system which then limits the amount of calories and nutrients that body can absorb Treatment with a large malabsorptive component results in the most weight loss but tend to have slightly higher complication rates

1JEJUNAL ILEAL BYPASS ndash no longer performed for high complication rates

2ILEAL TRANSPOSITION- New malabsoptive procedure on trial for treatment of DM type 2 and metabolic disorders

C COMBINATION PROCEDURES RESTRICTIVE + MALABSORBTIVE

1LAP GASTRIC BYPASS ndash ROUX-EN- Y ndash more malabsorption than the restrictive

2MINI- GASTRIC BYPASS- mainly restrictive

3DUODENAL SWITCH ndash the sleeve stomach is the restrictive portion ampthe intestinal bypass (duodenal switch) is the malabsorptive component

When surgery combines both restrictive and malabsorptive techniques it is know as a ldquocombinationrdquo procedure Most types of bariatric surgery carry at least a small element of both components but the following surgeries achieve a notable portion of weight loss from eachhellip

1 LAP GASTRIC BYPASS LGB

The Roux-en-Y gastric bypass(known simply as the LRYGBP) is the most commonly performed procedure

It primarily causesweight loss by restricting thefood intake however there ismore amount of mal absorption that occurs with this operation

GASTRIC BYPASS LRYGBP

bullThe stomach is stapled into2 pieces one small and one large The small piece becomes the ldquonewrdquo stomach pouch

bull The larger portion of the stomach stays in place however will lie dormant for the remainder of the patientrsquos life

GASTRIC BYPASS LGB

bull The small intestine (the jejunum) is divided using a surgical staplerApprox 50-70 cm from the DJ Junction

GASTRIC BYPASS LGB

Y- LIMB BP LIMB

bull The end of the Roux limb is then attached to the newly formed stomach pouch which carries food to the distal intestine

bull The Roux loop is completed by forming a jejunostomy

bull The Y limb or BPD limb carries digestive juices from the pancreas gall bladder liver and duodenum to the intestines

bull The food and the digestive juices mix where the Roux limb and Y limb meet much below say 100-150 cm from DJ

Roux limb or alimentary limb

100-150 cm

How Does the Roux-en-Y Work

Surgery factors restriction of meal size ldquodumping syndromerdquo some malabsorption decreased appetite

Patient factors calorie intake calorie expenditure

bull Most commonly performedbull Most reliable operation for long term weight lossbull Long term weight loss averages 60 to 75 percent of EBWbull Malnutrition is unusualbull Substantial improvement amp resolution in many co-morbid

obesity conditions

ADVANTAGES OF RYGBP

1 Not reversible

2 Mortality 05- 1

3 Perioperative complications 5-10

4 Stricture of gastrojejunostomy-10 (long term)

5 Long term risk of protein amp vitamin deficiency and marginal ulceration of GJA

6Long term risk of intestinal obstruction ndash 2

LAPAROSCOPIC GASTRIC BYPASSCOMPLICATIONS

Biliopancreatic Diversion (BPD)

Primarily malabsorptive but restrictive component also

First Terminal ileum is measured to a length of 50 cms marked with suture

The alimentary tract beyond the proximal part of stomach is rearranged to

include only distal 200 cm of ileum including common channel

Common channel-Distal 50 cm of terminal ileum for absorption of fat and

protein

The proximal end of ileum anastomosed to proximal end of stomach after

performing distal hemigastrectomy

Biliopancreatic Diversion with Duodenal Switch

Modification to lessen high incidence of vit b12 deficiency anastomotic stricture at gastrojejunal anastomosis

This procedure involves a sleeve gastrectomy that is then diverted at the duodenum into the ileum at a point measured proximally from the ileocecal valve (usually 250 cm)

The distal duodenum and jejunum the biliopancreatic limb are then anastomosed to the ileum at a point measured proximally from the ileocecal valve (usually 100 cm)

Common channel is 100cm Entire alimentary tract is 250 cm This is the most aggressive bypass procedure commonly offered today Major difference-Sleeve gastrectomy instead of distal hemigastrectomy

bull Most women regained normal menstrual function and most had documented

spontaneous ovulation

bull Significant improvement in hirsutism androgen profiles and about a 50 reduction in

HOMA-IR

bull Follow up for more than 2 years showed that all women resumed normal menstrual

cycles HbA1C decreased from 82 to 51 in lt 3 months

bull 78 saw improvement in metabolic syndrome amp 48 showed improvement in PCOS

2 ROLE OF BARIATRIC SURGERY IN PCOS PATIENTS

bull Decrease menstrual irregularities bull PCOS women have less hyper androgenism

bull Sex hormone binding globulin increases bull LH and FSH levels have been reported to increase

bull Ovulatory function measured by luteal LH and Progesterone secretion improved bull Leptin levels decrease reflecting improved reproductive metabolic status

bull Subclinical hypothyroidism significantly reduced

THE SAFE TIMING OF PREGNANCYoptimal or minimal time gt12 months after bariatric surgery before becoming pregnant in order to allow the rapid weight loss and metabolic changes to subside

4 BARIATRIC SURGERY IN REPRODUCTIVE WOMEN

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)

The foregut hypothesis theory ndash 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

Effect of Bariatric Surgery on Diabetes Mellitus

Combined Gastric Restriction amp Malabsorption

Operative Risks (vs cholecystectomy)

Perioperative Mortality 1-2 vs 02-08 Early Complications 10 vs 29Late Complications 20 vs 1-2

LimitationsWidening of (unbanded) gastrojejunostomyExpansion of gastric pouch 25 with nearly 100 weight regainAdaptation of limb that receives the food

SUMMARY OF ALL TYPES OF SURGERY

bull LRYGBP ndash worlds best procedure 60-70 WL dumping syndrome malnutrition

bull LAGB- low complications varying range of wt loss frequent post-op visits ( 10)

bull DSBPD- more wt loss high complications good for high BMI gt 50 malabsorption +

bull VBG(vertical band gastroplasty) ndash longest available results good wt loss improved co-morbidities right for some ptsrisks too high to justify rewards

bull SG- needs long term research 1st step procedure low risks higher wt loss lesser complications pouch could Stretch over time long staple line could cause problems in future frequency is accelerating because of technical ease 1st stage procedure before bypass

Post-surgical Complications

Anastomosis leaks or staple line leaks Pulmonary Embolism or DVT Cholelithiasis Stomal ulceration Dumping syndrome Constipation

Anastamosis Leaks

Up to 7-10 days after surgery Most common at gastrojejunostomy enteroenterostomy Roux

limb stump staple line Can lead to peritonitis sepsis possible death Presentation

Tachycardia tachypnea Fever Ab painback pain Pelvic pressure or rebound tenderness

Anastamosis Leaks

Order Gastrograffin upper GI series Subclinical cases

Bowel rest Parenteral nutrition IV antibiotic if H pylori

Clinically suspect leak Laparoscopic evaluation and leak repair

Failure to evaluate is the most common cause of preventable major long-term disability or death in bariatric surgical patients

Pulmonary Embolism

Sudden cause of death up to one month after surgery 20-30 mortality rate High risk may have vena cava filter placement prior to surgery Prophylaxis with compression stockings and LMWH Early ambulation imperitive

Pulmonary Embolism

Presentation Profound hypoxia Hypotension Signs of sepsis

Immediate spiral chest CT Abdominal exploration if too large for machine No pathology start anticoagulation Too largehelliphellipNO SURGERY

Cholelithiasis

Up to 36 of patients within 6 months post-op Bile stasis leads to increased sludge and gallstones Prophylactic cholecystectomy prior to surgery if

evidence of existing sludge or stones Prevent post-operative disease with concurrent bariatric

surgery and cholecystectomy Prophylactic use of urosidol

Expensive and unpalatable

Stomal Ulceration

12-15 within 2-4 mos Post-surgery Etiology

Overabundant acid in pouch leads to excessive acid passing through stoma

Pouch tension and staple line breakdown NSAID use

Presentation Dyspepsia vomiting Epigastric or retrosternal pain

Stomal Ulceration

Treatment PPI carafate Antibiotics if H Pylori Avoid NSAIDS alcohol smoking

If no response to treatment Endoscopy Back to surgery for pouch revision or staple line repair

Dumping Syndrome

More than 15 patients Hypotention Tachycardia Lightheadedness syncope Flushing Abdominal cramping and diarrhea Nausea and vomiting

Dumping Syndrome

Occurs with high dose simple sugar ingestion Sugar in small intestine causes osmotic overload and fluid

shift from blood to intestine Increased intestinal volume leads to watery diarrhea Decreased blood volume leads to systemic changes Patient education

Eat slowly Avoid drinking before during and not until 30 minutes after meals

Constipation

Most common complaint Causes

Dehydration and decreased fluid intake post-operatively Increased metabolic water needs Calcium and iron supplement use following surgery

Treat with increased fluids and stool softeners

Nutritional Consequences

Iron deficiency anemia B12 deficiency Folate deficiency Calcium and Vitamin D deficiency

Not seen with purely restrictive surgeries

Iron deficiency and anemia

Common following RYGB As high as 49 of patients Multifactorial cause

Low gastric acid levels prohibit iron cleavage from food Absorption inhibited because no nutrient exposure to duodenum or

proximal jejunum Decrease in iron-rich food consumption due to intolerance

Treat with oral supplementation of ferrous sulfate or ferrous gluconate

Vitamin B12 deficiency

Up to 70 of patients Lack of hydrochloric acid and pepsin in stomach

Prevents B12 cleavage from food Affects secretion of intrinsic factor thus B12 absorption

Intolerance to meat and milk Oral supplementation usually adequate otherwise IM injections used

Folate Deficiency

40 of gastric bypass patients Complete absorption requires B12 Absorption dependent on HCl and upper 13 stomach Deficiency generally caused by decreased consumption Oral supplementation

Vitamin D and Calcium Deficiency

Vitamin D deficiency is common among obese people Calcium absorption decreased because duodenum is

bypassed Intolerance to dairy foods high in calcium Vitamin D is required for Ca++ absorption Prolonged deficiencies lead to

Bone resorption osteomalacia osteoporosis Treat with calcium citrate supplementation and 2 weekly

doses of Vitamin D

Nutritional Implications of Various Bariatric Surgeries(34)

bull RYGB Malabsorption of Vit B12 Vit B1 (thiamin) Vit D Vit K Folate Iron Calcium

bull LAGB Folic Acid deficiency

bull BPD and BPDDS Vit A D E and K deficiency Protein-Calorie Malnutrition Malabsorption of

Calcium Zinc Selenium Sodium Potassium Chloride Phosphorus Magnesium

Recommended Daily Supplements(4)

Multivitamin with iron (prenatal vitamin will have adeq amount of folic acid)

Calcium (citrate) with vitamin D (1200-1500 mg calcium with 800-1000 IU vitamin D)

Oral vitamin B12 (500-1000 mcg) Iron (65 mgday in elemental form)

Vitamin C (to increase absorption of Iron) Thiamin (10 mgday)

Diet Recommendations(3)

Reduce food volume Chew food very well Slow pace of eating No liquids with meals Encourage fruits and vegetables as diet progresses Include high protein foods (at least 60gday) may need protein

supplements

Diet Progression Gastric Bypass

Stage 1 Clear liquids and protein supplement (1 week)

Stage 2No concentrated sweets low fat puree diet ( 3 weeks)

Stage 3 Regular texture weight reduction diet

Diet Progression Lap - Band

Stage 1 Clear liquids and protein supplement ( 2 weeks)

Stage 2 No concentrated sweets low fat puree diet (2weeks)

Stage 3 Regular texture weight reduction diet

Stage 1

Only clear liquids allowed Avoid sweetened beverages Sip very slowly No straws Avoid caffeinated carbonated and alcoholic beverages STOP drinking if you feel fullness pain or discomfort

Protein supplements

Begin the day after you go home from Hospital

Minimum protein target 70gmsday

May use powder or pre-mixed liquid forms (Whey protein is preferred)

Protein pills may not be used

Vitamin and Mineral Supplements

Gastric bypass patients In addition to eating much less food gastric bypass patients will also

absorb vitamins and minerals differently after surgery They will require daily multivitamin calcium and iron

supplementation for the rest of your life

Vitamin and Mineral Supplements

Lap-Bandreg patients

Require a multivitamin with minerals daily

It may be necessary to take additional vitamins and minerals eg calcium iron folateB1 B12These will be prescribed as needed

Stage 2 dietPUREE

Puree diet

Regular scheduled meals Avoid meal skipping Plan meals in advance Eat Slowly Eat protein foods first Moisten meats Use liquid protein as supplement not as meal replacement

Measure 2 oz portions at each meal eating when full Separate liquids and solids No bread rice or pasta Avoid added sugars and high fat

foods VARIETY

Side Effects

GI side effects due to inhibition of fat absorption pain fecal urgency liquid stools flatulence with discharge

oily spotting

Why Diets Often Fail

Require lot of time and energy

Cause feelings of deprivation

Donrsquot address why people overeat

Disrupt metabolism

Why SurgeryDiet and exercise are not effective

long term in the morbidly obese Surgery is an accepted and effective approach Medical co-morbidities are improvedresolved Increases life expectancy Decreases health care costs Surgical risk is acceptable vs risk of long-term obesity

RESOLUTION OF DISEASES FOLLOWING BARIATRIC SURGERY

Who Is a Surgical Candidate BMI gt 40 kgm2

-OR- BMI gt 35 kgm2 and major medical complications of

obesity-AND-

Failure of other approaches to long-term weight loss Age 18-55(relative)

Recommended BMI values for Bariatric Surgery in Asians

BMI ge 375

BMI ge 325 with two

associated co-

morbidities

No endocrine cause of obesity Acceptable operative risk Understands surgery and risks Absence of drug or alcohol problem No uncontrolled psychological conditions Consensus after bariatric team

evaluation SurgeonDieticianPsychologistConsultant

Dedicated to life-style change and follow-up

Obesity multidisciplinary team

Surgeon Physician Anesthetist Dietician Specialist bariatric nurse Skilled theatre staff Psychiatrist

Bariatric Surgery and Diabetes

International Diabetes Federation (2011) Journal of Diabetes (3(2011) 261-264) ldquoBariatric surgery is an appropriate treatment of people with T2D and

obesity who are not achieving recommended treatment targets with existing medical therapies especially in the presence of other major comorbiditiesrdquo

lt1 of those eligible actually have WLS for diabetes

Contraindications

Factors that may be considered contraindications include unstable CAD uncontrolled severe OSA uncontrolled psychiatric disorder mental retardation (IQ lt 60) inability to understand the surgery perceived inability to adhere to postoperative restrictions continued drug abuse malignancy with a poor 5-year survival prognosis Cirrhotic liver disease with portal hypertension

Preoperative EvaluationAttention should focus on issues unique to the obese patient

particularly cardiorespiratory status and the airwayConsideration of co morbidities ie hypertension diabetes heart

failure IHD obesity-hypoventilation syndrome metabolic syndrome etc

Results of the sleep study History of previous surgeries their anesthetic challenges need for

ICU admissionCurrent medicationsPatients scheduled for repeat bariatric surgery should be screened

preoperatively for long-term metabolic and nutritional abnormalities

Investigationshellip Recommended preoperative laboratory evaluations include

fasting blood glucose lipid profile electrolytes serum chemistries (to evaluate renal and hepatic function) complete blood count Serum ferritin vitamin B12 thyrotropin amp 25-hydroxyvitamin D

(Miller 7th edition- anesthesia for Bariatic Surgery) ABG measurements help evaluate ventilation as well as the need for perioperative oxygen administration and

postoperative ventilation Routine pulmonary function tests and liver function tests are not cost-effective in asymptomatic obese patients Coaugulation profile ( liver problem repeat surgery orlistat) ECG echocardiography Sleep study if suspected OSA

(Barash 6th edition anesthesia and obesity)

Concurrent Preoperative and Prophylactic Medications

Patients usual medications should be continued until the time of surgery with the possible exception of insulin and oral hypoglycemics

Antibiotic prophylaxis is usually indicated

Obesity itself does not increase the risk for aspiration acid aspiration prophylaxis including H2 receptor agonists or proton pump inhibitors must be considered in patients with identifiable risk for aspiration

Anxiolysis and prophylaxis against deep vein thrombosis (DVT) should be addressed at premedication

DVT consideration Morbid obesity is a major independent risk factor for sudden death from

acute postoperative pulmonary embolism Subcutaneous heparin 5000 IU administered before surgery and repeated every 8 to 12

hours until the patient is fully mobile reduces the risk of DVT LMWH can also be used

Preoperative prophylactic placement of an inferior vena cava filter should be considered in venous stasis disease BMI ge60 truncal obesity and OSA

What Are the Risks

MAJOR RISKS Death (1 of patients die within 30 days) Severe malnutrition (anemia PEM osteomalacia) Peritonitis (from leakage or ruptures at staple sites)

or other infection Obstructions caused by scar tissue in the stomach or

bowels

MINOR RISKS Dumping Syndrome (unpleasant but not harmful) Diarrhea and malodorous gas production Lactose intolerance Hair loss (short-term post-surgery) May have to eventually undergo surgical revision Pain post-surgery

History of Bariatric Surgery

Obesity surgery is not a new discipline The earliest Bariatric procedure performed was in 1954 at Minnesota The procedure

was Jejuno-ileal bypass In 1966Gastric Bypass was introduced as a surgical procedure for weight loss at the

University of Iowa In 1977Griffen reported the first Roux-en-Y Gastric Bypass In 1980surgeons with a more conservative approach developed the Vertical Banded

Gastroplasty Other procedures with longer intestinal segment bypass were also introduced such as

Biliopancreatic Diversions These complex procedures are recommended in super-obese patients ie BMIgt60

How does surgery work

RESTRICTIVE - RESTRICT AMOUNT OF FOOD INGESTED Decreases appetitehunger

Early satiety Behavior modification Gastric Banding (Lap Band)

Roux-en Y Gastric bypass (RYGB) Sleeve Gastrectomy

MALABSORPTIVE- LIMITS DIGESTION AND ABSORPTION Decreases length of intestine exposed to digested food

25 of fat is absorbed Behavior modification

Biliopancreatic Diversion Duodenal Switch (BPDDS)

ALL OPERATIONS CAN BE PERFORMED OPEN OR LAPAROSCOPICALLY

Laparoscopic vs Open

OPEN uarr post op pain Longer hospitalizations uarr wound complications

Infection Hernias Seromas

Return to work in 4-8 weeks

LAPAROSCOPIC darr post op pain Early mobility darr Wound complications 2-3 day hospital stay Return to work in 1-3 weeks

1 Nguyen NT et al Accelerated growth of bariatric surgery with the introduction of minimally invasive surgery Arch Surg 20051401198-202

Procedures that are solely restrictive by creating a small gastric pouch of volume 15 to 30 cc amp a degree of outlet obstruction leading to delayed gastric emptying The goal is to reduce oral intake by limiting gastric volume produce early satiety and leave the alimentary canal in continuity minimizing the risks of metabolic complications

1VERTICAL BANDED GASTROPLASTY

2ADJUSTABLE GASTRIC BANDING (LAGB )

3 SLEEVE GASTRECTOMY

4GASTRIC PLICATION

5 INTRA GASTRIC BALLOON (GASTRIC BALLOON)

RESTRICTIVE PROCEDURES

Malabsorption is achieved by creating a short gut syndrome andor by accomplishing distal mixing of bile and pancreatic juice with ingested nutrients thereby reducing absorption Some purely malabsorptive operations are no longer recommended due to their potential hazard to cause serious nutritional deficiencies

1 BILIOPANCREATIC DIVERSION2 THE JEJUNAL-ILEAL BYPASS3 ENDOLUMINAL SLEEVE

MALABSORPTIVE PROCEDURES

MIXED PROCEDURES

1GASTRIC BYPASS ROUX-EN-Y ( RYGBP)

2SLEEVE GASTRECTOMY WITH DUODENAL SWITCH

3IMPLANTABLE 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

The stomach is partitioned along its axis with a non-

adjustable poly-urethane band and with linear amp 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 was practiced in 1980

Vertical Banded Gastroplasty (VBG)

ADJUSTABLE GASTRIC BANDING (LAP BAND SURGERY LAGB)

Restrictive Procedure The procedure was first performed by Cadiere in 1992 but was made popular by Belachew and Legrand in 1993 An inflatable silicone BAND is placed around the top portion of the stomach to form a small stomach pouch amp sewed

This band is connected to a tube that leads to a port above the abdominal muscles placed below the skin (FILL ndash PORT)

During follow up visits we inject or remove saline solution to make the band tighter or looser

Adjustable Gastric Band

bull 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

How does the Band work

Surgery Factors Restriction of meal size Decreased appetite

Patient Factors Decreased calorie intake Increased calorie expenditure

LAP-BAND Adjustability

Unfilled Band Filled Band

Adjustments are made in the office

Complications of Gastric Lap-Band

bull Perforation of Stomachbull Slippagebull Gastric Erosion(much less after Pars flaccida technique) bull Dilated Esophagusbull Tubing access port problemsbull Mal positioningbull Abdominal Painbull Heartburnbull Vomitingbull Inability to Adjust the Bandbull Failure to Lose Weightbull Infection of Systembull Fatigue or malfunction

Advantages

No intestinal surgery No staplingcutting of stomach No nutritional risks Adjustable Reversible Safe

Foreign body Frequent follow-up visits Needs more commitment Easy to cheat

Disadvantages

Comparison of Adjustable Gastric Banding and Vertical Banded Gastroplasty

Laparoscopic adjustable gastric banding Reversible Adjustable Simpler to perform laparoscopically Sustained weight loss of gt50 EBW gt5

years following surgery Complications Gastric prolapse band

erosion rarely gastric perforation and access port complications

Vertical banded gastroplasty Irreversible Non adjustable Technically difficult by laparoscopy Weight loss of 25-50 EBW and weight gain

after 2-3 years Complications suture line disruption gastric

leak weight gain

>

>

Originally used as the first-stage operation for a proposed biliopancreatic diversion with duodenal switch in high-risk patients

The sleeve gastrectomy has caught on as a primary obesity treatment as surgeons are reporting weight loss of 55 of excess body weight past 5 years in some patients

The sleeve gastrectomy is also known as the greater curvature gastrectomy vertical or longitudinal gastrectomy or Pylorus preserving lsquogastric tube creationrsquo

Rapid and less traumatic operation Good resolution of co-morbidities and good weight loss

A further second surgical step is then easily feasible if necessary

SLEEVE GASTRECTOMY

SLEEVE GASTRECTOMY

A sleeve gastrectomy involves resection of

approximately 80 of the greater curvature

side of the stomach

Smaller tubular gastric ldquosleeverdquo created

along the lesser curve that is based on the

lesser curvature blood supply

Ideal approximate capacity of the stomach

after the procedure is about 30- 60 ml pouch

1MECHANICAL RESTRICTION by reducing the volume of the stomach and impairing stomach mobility Also called lsquoFood limitingrsquo operation

2HORMONAL MODIFICATION by removing a great part of the Ghrelin (Hunger Hormone) production tissue

(Ghrelin is a 28 amino-acid-peptide secreted by the oxyntic glands of the gastric fungus It is a potent orexigenic (appetite-stimulating) peptide mediated by the activation of its receptors in the hypothalamus or pituitary area)

The gastric fundus contains 10 to 20 times more ghrelin per one gram of tissue than the duodenum In the SG resection of the fundus removes the major portion of ghrelin release therefore appetite decreases

The sleeve gastrectomy (SG) induces weight loss by 2 mechanisms

>

Intragastric balloon involves placing a deflated balloon into the stomach and then filling it to decrease the amount of gastric space

The balloon can be left in the stomach for a maximum of 6 months and results in an average weight loss of 5ndash9 BMI over half a year

Done endoscopically

The intragastric balloon may be used prior to another bariatric surgery as a step-down procedure

INTRA GASTRIC BALLOON

>

>

The EndoBarrier gastrointestinal liner mimics the effects of gastric bypass surgery

Itrsquos designed to work by inserting a flexible

tube-like barrier into the duodenum amp 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

ENDO BARRIER LINER SYSTEM

B MAL- ABSORPTIVE PROCEDURES

Malabsorptive surgeries rearrange andor remove part of digestive system which then limits the amount of calories and nutrients that body can absorb Treatment with a large malabsorptive component results in the most weight loss but tend to have slightly higher complication rates

1JEJUNAL ILEAL BYPASS ndash no longer performed for high complication rates

2ILEAL TRANSPOSITION- New malabsoptive procedure on trial for treatment of DM type 2 and metabolic disorders

C COMBINATION PROCEDURES RESTRICTIVE + MALABSORBTIVE

1LAP GASTRIC BYPASS ndash ROUX-EN- Y ndash more malabsorption than the restrictive

2MINI- GASTRIC BYPASS- mainly restrictive

3DUODENAL SWITCH ndash the sleeve stomach is the restrictive portion ampthe intestinal bypass (duodenal switch) is the malabsorptive component

When surgery combines both restrictive and malabsorptive techniques it is know as a ldquocombinationrdquo procedure Most types of bariatric surgery carry at least a small element of both components but the following surgeries achieve a notable portion of weight loss from eachhellip

1 LAP GASTRIC BYPASS LGB

The Roux-en-Y gastric bypass(known simply as the LRYGBP) is the most commonly performed procedure

It primarily causesweight loss by restricting thefood intake however there ismore amount of mal absorption that occurs with this operation

GASTRIC BYPASS LRYGBP

bullThe stomach is stapled into2 pieces one small and one large The small piece becomes the ldquonewrdquo stomach pouch

bull The larger portion of the stomach stays in place however will lie dormant for the remainder of the patientrsquos life

GASTRIC BYPASS LGB

bull The small intestine (the jejunum) is divided using a surgical staplerApprox 50-70 cm from the DJ Junction

GASTRIC BYPASS LGB

Y- LIMB BP LIMB

bull The end of the Roux limb is then attached to the newly formed stomach pouch which carries food to the distal intestine

bull The Roux loop is completed by forming a jejunostomy

bull The Y limb or BPD limb carries digestive juices from the pancreas gall bladder liver and duodenum to the intestines

bull The food and the digestive juices mix where the Roux limb and Y limb meet much below say 100-150 cm from DJ

Roux limb or alimentary limb

100-150 cm

How Does the Roux-en-Y Work

Surgery factors restriction of meal size ldquodumping syndromerdquo some malabsorption decreased appetite

Patient factors calorie intake calorie expenditure

bull Most commonly performedbull Most reliable operation for long term weight lossbull Long term weight loss averages 60 to 75 percent of EBWbull Malnutrition is unusualbull Substantial improvement amp resolution in many co-morbid

obesity conditions

ADVANTAGES OF RYGBP

1 Not reversible

2 Mortality 05- 1

3 Perioperative complications 5-10

4 Stricture of gastrojejunostomy-10 (long term)

5 Long term risk of protein amp vitamin deficiency and marginal ulceration of GJA

6Long term risk of intestinal obstruction ndash 2

LAPAROSCOPIC GASTRIC BYPASSCOMPLICATIONS

Biliopancreatic Diversion (BPD)

Primarily malabsorptive but restrictive component also

First Terminal ileum is measured to a length of 50 cms marked with suture

The alimentary tract beyond the proximal part of stomach is rearranged to

include only distal 200 cm of ileum including common channel

Common channel-Distal 50 cm of terminal ileum for absorption of fat and

protein

The proximal end of ileum anastomosed to proximal end of stomach after

performing distal hemigastrectomy

Biliopancreatic Diversion with Duodenal Switch

Modification to lessen high incidence of vit b12 deficiency anastomotic stricture at gastrojejunal anastomosis

This procedure involves a sleeve gastrectomy that is then diverted at the duodenum into the ileum at a point measured proximally from the ileocecal valve (usually 250 cm)

The distal duodenum and jejunum the biliopancreatic limb are then anastomosed to the ileum at a point measured proximally from the ileocecal valve (usually 100 cm)

Common channel is 100cm Entire alimentary tract is 250 cm This is the most aggressive bypass procedure commonly offered today Major difference-Sleeve gastrectomy instead of distal hemigastrectomy

bull Most women regained normal menstrual function and most had documented

spontaneous ovulation

bull Significant improvement in hirsutism androgen profiles and about a 50 reduction in

HOMA-IR

bull Follow up for more than 2 years showed that all women resumed normal menstrual

cycles HbA1C decreased from 82 to 51 in lt 3 months

bull 78 saw improvement in metabolic syndrome amp 48 showed improvement in PCOS

2 ROLE OF BARIATRIC SURGERY IN PCOS PATIENTS

bull Decrease menstrual irregularities bull PCOS women have less hyper androgenism

bull Sex hormone binding globulin increases bull LH and FSH levels have been reported to increase

bull Ovulatory function measured by luteal LH and Progesterone secretion improved bull Leptin levels decrease reflecting improved reproductive metabolic status

bull Subclinical hypothyroidism significantly reduced

THE SAFE TIMING OF PREGNANCYoptimal or minimal time gt12 months after bariatric surgery before becoming pregnant in order to allow the rapid weight loss and metabolic changes to subside

4 BARIATRIC SURGERY IN REPRODUCTIVE WOMEN

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)

The foregut hypothesis theory ndash 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

Effect of Bariatric Surgery on Diabetes Mellitus

Combined Gastric Restriction amp Malabsorption

Operative Risks (vs cholecystectomy)

Perioperative Mortality 1-2 vs 02-08 Early Complications 10 vs 29Late Complications 20 vs 1-2

LimitationsWidening of (unbanded) gastrojejunostomyExpansion of gastric pouch 25 with nearly 100 weight regainAdaptation of limb that receives the food

SUMMARY OF ALL TYPES OF SURGERY

bull LRYGBP ndash worlds best procedure 60-70 WL dumping syndrome malnutrition

bull LAGB- low complications varying range of wt loss frequent post-op visits ( 10)

bull DSBPD- more wt loss high complications good for high BMI gt 50 malabsorption +

bull VBG(vertical band gastroplasty) ndash longest available results good wt loss improved co-morbidities right for some ptsrisks too high to justify rewards

bull SG- needs long term research 1st step procedure low risks higher wt loss lesser complications pouch could Stretch over time long staple line could cause problems in future frequency is accelerating because of technical ease 1st stage procedure before bypass

Post-surgical Complications

Anastomosis leaks or staple line leaks Pulmonary Embolism or DVT Cholelithiasis Stomal ulceration Dumping syndrome Constipation

Anastamosis Leaks

Up to 7-10 days after surgery Most common at gastrojejunostomy enteroenterostomy Roux

limb stump staple line Can lead to peritonitis sepsis possible death Presentation

Tachycardia tachypnea Fever Ab painback pain Pelvic pressure or rebound tenderness

Anastamosis Leaks

Order Gastrograffin upper GI series Subclinical cases

Bowel rest Parenteral nutrition IV antibiotic if H pylori

Clinically suspect leak Laparoscopic evaluation and leak repair

Failure to evaluate is the most common cause of preventable major long-term disability or death in bariatric surgical patients

Pulmonary Embolism

Sudden cause of death up to one month after surgery 20-30 mortality rate High risk may have vena cava filter placement prior to surgery Prophylaxis with compression stockings and LMWH Early ambulation imperitive

Pulmonary Embolism

Presentation Profound hypoxia Hypotension Signs of sepsis

Immediate spiral chest CT Abdominal exploration if too large for machine No pathology start anticoagulation Too largehelliphellipNO SURGERY

Cholelithiasis

Up to 36 of patients within 6 months post-op Bile stasis leads to increased sludge and gallstones Prophylactic cholecystectomy prior to surgery if

evidence of existing sludge or stones Prevent post-operative disease with concurrent bariatric

surgery and cholecystectomy Prophylactic use of urosidol

Expensive and unpalatable

Stomal Ulceration

12-15 within 2-4 mos Post-surgery Etiology

Overabundant acid in pouch leads to excessive acid passing through stoma

Pouch tension and staple line breakdown NSAID use

Presentation Dyspepsia vomiting Epigastric or retrosternal pain

Stomal Ulceration

Treatment PPI carafate Antibiotics if H Pylori Avoid NSAIDS alcohol smoking

If no response to treatment Endoscopy Back to surgery for pouch revision or staple line repair

Dumping Syndrome

More than 15 patients Hypotention Tachycardia Lightheadedness syncope Flushing Abdominal cramping and diarrhea Nausea and vomiting

Dumping Syndrome

Occurs with high dose simple sugar ingestion Sugar in small intestine causes osmotic overload and fluid

shift from blood to intestine Increased intestinal volume leads to watery diarrhea Decreased blood volume leads to systemic changes Patient education

Eat slowly Avoid drinking before during and not until 30 minutes after meals

Constipation

Most common complaint Causes

Dehydration and decreased fluid intake post-operatively Increased metabolic water needs Calcium and iron supplement use following surgery

Treat with increased fluids and stool softeners

Nutritional Consequences

Iron deficiency anemia B12 deficiency Folate deficiency Calcium and Vitamin D deficiency

Not seen with purely restrictive surgeries

Iron deficiency and anemia

Common following RYGB As high as 49 of patients Multifactorial cause

Low gastric acid levels prohibit iron cleavage from food Absorption inhibited because no nutrient exposure to duodenum or

proximal jejunum Decrease in iron-rich food consumption due to intolerance

Treat with oral supplementation of ferrous sulfate or ferrous gluconate

Vitamin B12 deficiency

Up to 70 of patients Lack of hydrochloric acid and pepsin in stomach

Prevents B12 cleavage from food Affects secretion of intrinsic factor thus B12 absorption

Intolerance to meat and milk Oral supplementation usually adequate otherwise IM injections used

Folate Deficiency

40 of gastric bypass patients Complete absorption requires B12 Absorption dependent on HCl and upper 13 stomach Deficiency generally caused by decreased consumption Oral supplementation

Vitamin D and Calcium Deficiency

Vitamin D deficiency is common among obese people Calcium absorption decreased because duodenum is

bypassed Intolerance to dairy foods high in calcium Vitamin D is required for Ca++ absorption Prolonged deficiencies lead to

Bone resorption osteomalacia osteoporosis Treat with calcium citrate supplementation and 2 weekly

doses of Vitamin D

Nutritional Implications of Various Bariatric Surgeries(34)

bull RYGB Malabsorption of Vit B12 Vit B1 (thiamin) Vit D Vit K Folate Iron Calcium

bull LAGB Folic Acid deficiency

bull BPD and BPDDS Vit A D E and K deficiency Protein-Calorie Malnutrition Malabsorption of

Calcium Zinc Selenium Sodium Potassium Chloride Phosphorus Magnesium

Recommended Daily Supplements(4)

Multivitamin with iron (prenatal vitamin will have adeq amount of folic acid)

Calcium (citrate) with vitamin D (1200-1500 mg calcium with 800-1000 IU vitamin D)

Oral vitamin B12 (500-1000 mcg) Iron (65 mgday in elemental form)

Vitamin C (to increase absorption of Iron) Thiamin (10 mgday)

Diet Recommendations(3)

Reduce food volume Chew food very well Slow pace of eating No liquids with meals Encourage fruits and vegetables as diet progresses Include high protein foods (at least 60gday) may need protein

supplements

Diet Progression Gastric Bypass

Stage 1 Clear liquids and protein supplement (1 week)

Stage 2No concentrated sweets low fat puree diet ( 3 weeks)

Stage 3 Regular texture weight reduction diet

Diet Progression Lap - Band

Stage 1 Clear liquids and protein supplement ( 2 weeks)

Stage 2 No concentrated sweets low fat puree diet (2weeks)

Stage 3 Regular texture weight reduction diet

Stage 1

Only clear liquids allowed Avoid sweetened beverages Sip very slowly No straws Avoid caffeinated carbonated and alcoholic beverages STOP drinking if you feel fullness pain or discomfort

Protein supplements

Begin the day after you go home from Hospital

Minimum protein target 70gmsday

May use powder or pre-mixed liquid forms (Whey protein is preferred)

Protein pills may not be used

Vitamin and Mineral Supplements

Gastric bypass patients In addition to eating much less food gastric bypass patients will also

absorb vitamins and minerals differently after surgery They will require daily multivitamin calcium and iron

supplementation for the rest of your life

Vitamin and Mineral Supplements

Lap-Bandreg patients

Require a multivitamin with minerals daily

It may be necessary to take additional vitamins and minerals eg calcium iron folateB1 B12These will be prescribed as needed

Stage 2 dietPUREE

Puree diet

Regular scheduled meals Avoid meal skipping Plan meals in advance Eat Slowly Eat protein foods first Moisten meats Use liquid protein as supplement not as meal replacement

Measure 2 oz portions at each meal eating when full Separate liquids and solids No bread rice or pasta Avoid added sugars and high fat

foods VARIETY

Why Diets Often Fail

Require lot of time and energy

Cause feelings of deprivation

Donrsquot address why people overeat

Disrupt metabolism

Why SurgeryDiet and exercise are not effective

long term in the morbidly obese Surgery is an accepted and effective approach Medical co-morbidities are improvedresolved Increases life expectancy Decreases health care costs Surgical risk is acceptable vs risk of long-term obesity

RESOLUTION OF DISEASES FOLLOWING BARIATRIC SURGERY

Who Is a Surgical Candidate BMI gt 40 kgm2

-OR- BMI gt 35 kgm2 and major medical complications of

obesity-AND-

Failure of other approaches to long-term weight loss Age 18-55(relative)

Recommended BMI values for Bariatric Surgery in Asians

BMI ge 375

BMI ge 325 with two

associated co-

morbidities

No endocrine cause of obesity Acceptable operative risk Understands surgery and risks Absence of drug or alcohol problem No uncontrolled psychological conditions Consensus after bariatric team

evaluation SurgeonDieticianPsychologistConsultant

Dedicated to life-style change and follow-up

Obesity multidisciplinary team

Surgeon Physician Anesthetist Dietician Specialist bariatric nurse Skilled theatre staff Psychiatrist

Bariatric Surgery and Diabetes

International Diabetes Federation (2011) Journal of Diabetes (3(2011) 261-264) ldquoBariatric surgery is an appropriate treatment of people with T2D and

obesity who are not achieving recommended treatment targets with existing medical therapies especially in the presence of other major comorbiditiesrdquo

lt1 of those eligible actually have WLS for diabetes

Contraindications

Factors that may be considered contraindications include unstable CAD uncontrolled severe OSA uncontrolled psychiatric disorder mental retardation (IQ lt 60) inability to understand the surgery perceived inability to adhere to postoperative restrictions continued drug abuse malignancy with a poor 5-year survival prognosis Cirrhotic liver disease with portal hypertension

Preoperative EvaluationAttention should focus on issues unique to the obese patient

particularly cardiorespiratory status and the airwayConsideration of co morbidities ie hypertension diabetes heart

failure IHD obesity-hypoventilation syndrome metabolic syndrome etc

Results of the sleep study History of previous surgeries their anesthetic challenges need for

ICU admissionCurrent medicationsPatients scheduled for repeat bariatric surgery should be screened

preoperatively for long-term metabolic and nutritional abnormalities

Investigationshellip Recommended preoperative laboratory evaluations include

fasting blood glucose lipid profile electrolytes serum chemistries (to evaluate renal and hepatic function) complete blood count Serum ferritin vitamin B12 thyrotropin amp 25-hydroxyvitamin D

(Miller 7th edition- anesthesia for Bariatic Surgery) ABG measurements help evaluate ventilation as well as the need for perioperative oxygen administration and

postoperative ventilation Routine pulmonary function tests and liver function tests are not cost-effective in asymptomatic obese patients Coaugulation profile ( liver problem repeat surgery orlistat) ECG echocardiography Sleep study if suspected OSA

(Barash 6th edition anesthesia and obesity)

Concurrent Preoperative and Prophylactic Medications

Patients usual medications should be continued until the time of surgery with the possible exception of insulin and oral hypoglycemics

Antibiotic prophylaxis is usually indicated

Obesity itself does not increase the risk for aspiration acid aspiration prophylaxis including H2 receptor agonists or proton pump inhibitors must be considered in patients with identifiable risk for aspiration

Anxiolysis and prophylaxis against deep vein thrombosis (DVT) should be addressed at premedication

DVT consideration Morbid obesity is a major independent risk factor for sudden death from

acute postoperative pulmonary embolism Subcutaneous heparin 5000 IU administered before surgery and repeated every 8 to 12

hours until the patient is fully mobile reduces the risk of DVT LMWH can also be used

Preoperative prophylactic placement of an inferior vena cava filter should be considered in venous stasis disease BMI ge60 truncal obesity and OSA

What Are the Risks

MAJOR RISKS Death (1 of patients die within 30 days) Severe malnutrition (anemia PEM osteomalacia) Peritonitis (from leakage or ruptures at staple sites)

or other infection Obstructions caused by scar tissue in the stomach or

bowels

MINOR RISKS Dumping Syndrome (unpleasant but not harmful) Diarrhea and malodorous gas production Lactose intolerance Hair loss (short-term post-surgery) May have to eventually undergo surgical revision Pain post-surgery

History of Bariatric Surgery

Obesity surgery is not a new discipline The earliest Bariatric procedure performed was in 1954 at Minnesota The procedure

was Jejuno-ileal bypass In 1966Gastric Bypass was introduced as a surgical procedure for weight loss at the

University of Iowa In 1977Griffen reported the first Roux-en-Y Gastric Bypass In 1980surgeons with a more conservative approach developed the Vertical Banded

Gastroplasty Other procedures with longer intestinal segment bypass were also introduced such as

Biliopancreatic Diversions These complex procedures are recommended in super-obese patients ie BMIgt60

How does surgery work

RESTRICTIVE - RESTRICT AMOUNT OF FOOD INGESTED Decreases appetitehunger

Early satiety Behavior modification Gastric Banding (Lap Band)

Roux-en Y Gastric bypass (RYGB) Sleeve Gastrectomy

MALABSORPTIVE- LIMITS DIGESTION AND ABSORPTION Decreases length of intestine exposed to digested food

25 of fat is absorbed Behavior modification

Biliopancreatic Diversion Duodenal Switch (BPDDS)

ALL OPERATIONS CAN BE PERFORMED OPEN OR LAPAROSCOPICALLY

Laparoscopic vs Open

OPEN uarr post op pain Longer hospitalizations uarr wound complications

Infection Hernias Seromas

Return to work in 4-8 weeks

LAPAROSCOPIC darr post op pain Early mobility darr Wound complications 2-3 day hospital stay Return to work in 1-3 weeks

1 Nguyen NT et al Accelerated growth of bariatric surgery with the introduction of minimally invasive surgery Arch Surg 20051401198-202

Procedures that are solely restrictive by creating a small gastric pouch of volume 15 to 30 cc amp a degree of outlet obstruction leading to delayed gastric emptying The goal is to reduce oral intake by limiting gastric volume produce early satiety and leave the alimentary canal in continuity minimizing the risks of metabolic complications

1VERTICAL BANDED GASTROPLASTY

2ADJUSTABLE GASTRIC BANDING (LAGB )

3 SLEEVE GASTRECTOMY

4GASTRIC PLICATION

5 INTRA GASTRIC BALLOON (GASTRIC BALLOON)

RESTRICTIVE PROCEDURES

Malabsorption is achieved by creating a short gut syndrome andor by accomplishing distal mixing of bile and pancreatic juice with ingested nutrients thereby reducing absorption Some purely malabsorptive operations are no longer recommended due to their potential hazard to cause serious nutritional deficiencies

1 BILIOPANCREATIC DIVERSION2 THE JEJUNAL-ILEAL BYPASS3 ENDOLUMINAL SLEEVE

MALABSORPTIVE PROCEDURES

MIXED PROCEDURES

1GASTRIC BYPASS ROUX-EN-Y ( RYGBP)

2SLEEVE GASTRECTOMY WITH DUODENAL SWITCH

3IMPLANTABLE 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

The stomach is partitioned along its axis with a non-

adjustable poly-urethane band and with linear amp 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 was practiced in 1980

Vertical Banded Gastroplasty (VBG)

ADJUSTABLE GASTRIC BANDING (LAP BAND SURGERY LAGB)

Restrictive Procedure The procedure was first performed by Cadiere in 1992 but was made popular by Belachew and Legrand in 1993 An inflatable silicone BAND is placed around the top portion of the stomach to form a small stomach pouch amp sewed

This band is connected to a tube that leads to a port above the abdominal muscles placed below the skin (FILL ndash PORT)

During follow up visits we inject or remove saline solution to make the band tighter or looser

Adjustable Gastric Band

bull 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

How does the Band work

Surgery Factors Restriction of meal size Decreased appetite

Patient Factors Decreased calorie intake Increased calorie expenditure

LAP-BAND Adjustability

Unfilled Band Filled Band

Adjustments are made in the office

Complications of Gastric Lap-Band

bull Perforation of Stomachbull Slippagebull Gastric Erosion(much less after Pars flaccida technique) bull Dilated Esophagusbull Tubing access port problemsbull Mal positioningbull Abdominal Painbull Heartburnbull Vomitingbull Inability to Adjust the Bandbull Failure to Lose Weightbull Infection of Systembull Fatigue or malfunction

Advantages

No intestinal surgery No staplingcutting of stomach No nutritional risks Adjustable Reversible Safe

Foreign body Frequent follow-up visits Needs more commitment Easy to cheat

Disadvantages

Comparison of Adjustable Gastric Banding and Vertical Banded Gastroplasty

Laparoscopic adjustable gastric banding Reversible Adjustable Simpler to perform laparoscopically Sustained weight loss of gt50 EBW gt5

years following surgery Complications Gastric prolapse band

erosion rarely gastric perforation and access port complications

Vertical banded gastroplasty Irreversible Non adjustable Technically difficult by laparoscopy Weight loss of 25-50 EBW and weight gain

after 2-3 years Complications suture line disruption gastric

leak weight gain

>

>

Originally used as the first-stage operation for a proposed biliopancreatic diversion with duodenal switch in high-risk patients

The sleeve gastrectomy has caught on as a primary obesity treatment as surgeons are reporting weight loss of 55 of excess body weight past 5 years in some patients

The sleeve gastrectomy is also known as the greater curvature gastrectomy vertical or longitudinal gastrectomy or Pylorus preserving lsquogastric tube creationrsquo

Rapid and less traumatic operation Good resolution of co-morbidities and good weight loss

A further second surgical step is then easily feasible if necessary

SLEEVE GASTRECTOMY

SLEEVE GASTRECTOMY

A sleeve gastrectomy involves resection of

approximately 80 of the greater curvature

side of the stomach

Smaller tubular gastric ldquosleeverdquo created

along the lesser curve that is based on the

lesser curvature blood supply

Ideal approximate capacity of the stomach

after the procedure is about 30- 60 ml pouch

1MECHANICAL RESTRICTION by reducing the volume of the stomach and impairing stomach mobility Also called lsquoFood limitingrsquo operation

2HORMONAL MODIFICATION by removing a great part of the Ghrelin (Hunger Hormone) production tissue

(Ghrelin is a 28 amino-acid-peptide secreted by the oxyntic glands of the gastric fungus It is a potent orexigenic (appetite-stimulating) peptide mediated by the activation of its receptors in the hypothalamus or pituitary area)

The gastric fundus contains 10 to 20 times more ghrelin per one gram of tissue than the duodenum In the SG resection of the fundus removes the major portion of ghrelin release therefore appetite decreases

The sleeve gastrectomy (SG) induces weight loss by 2 mechanisms

>

Intragastric balloon involves placing a deflated balloon into the stomach and then filling it to decrease the amount of gastric space

The balloon can be left in the stomach for a maximum of 6 months and results in an average weight loss of 5ndash9 BMI over half a year

Done endoscopically

The intragastric balloon may be used prior to another bariatric surgery as a step-down procedure

INTRA GASTRIC BALLOON

>

>

The EndoBarrier gastrointestinal liner mimics the effects of gastric bypass surgery

Itrsquos designed to work by inserting a flexible

tube-like barrier into the duodenum amp 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

ENDO BARRIER LINER SYSTEM

B MAL- ABSORPTIVE PROCEDURES

Malabsorptive surgeries rearrange andor remove part of digestive system which then limits the amount of calories and nutrients that body can absorb Treatment with a large malabsorptive component results in the most weight loss but tend to have slightly higher complication rates

1JEJUNAL ILEAL BYPASS ndash no longer performed for high complication rates

2ILEAL TRANSPOSITION- New malabsoptive procedure on trial for treatment of DM type 2 and metabolic disorders

C COMBINATION PROCEDURES RESTRICTIVE + MALABSORBTIVE

1LAP GASTRIC BYPASS ndash ROUX-EN- Y ndash more malabsorption than the restrictive

2MINI- GASTRIC BYPASS- mainly restrictive

3DUODENAL SWITCH ndash the sleeve stomach is the restrictive portion ampthe intestinal bypass (duodenal switch) is the malabsorptive component

When surgery combines both restrictive and malabsorptive techniques it is know as a ldquocombinationrdquo procedure Most types of bariatric surgery carry at least a small element of both components but the following surgeries achieve a notable portion of weight loss from eachhellip

1 LAP GASTRIC BYPASS LGB

The Roux-en-Y gastric bypass(known simply as the LRYGBP) is the most commonly performed procedure

It primarily causesweight loss by restricting thefood intake however there ismore amount of mal absorption that occurs with this operation

GASTRIC BYPASS LRYGBP

bullThe stomach is stapled into2 pieces one small and one large The small piece becomes the ldquonewrdquo stomach pouch

bull The larger portion of the stomach stays in place however will lie dormant for the remainder of the patientrsquos life

GASTRIC BYPASS LGB

bull The small intestine (the jejunum) is divided using a surgical staplerApprox 50-70 cm from the DJ Junction

GASTRIC BYPASS LGB

Y- LIMB BP LIMB

bull The end of the Roux limb is then attached to the newly formed stomach pouch which carries food to the distal intestine

bull The Roux loop is completed by forming a jejunostomy

bull The Y limb or BPD limb carries digestive juices from the pancreas gall bladder liver and duodenum to the intestines

bull The food and the digestive juices mix where the Roux limb and Y limb meet much below say 100-150 cm from DJ

Roux limb or alimentary limb

100-150 cm

How Does the Roux-en-Y Work

Surgery factors restriction of meal size ldquodumping syndromerdquo some malabsorption decreased appetite

Patient factors calorie intake calorie expenditure

bull Most commonly performedbull Most reliable operation for long term weight lossbull Long term weight loss averages 60 to 75 percent of EBWbull Malnutrition is unusualbull Substantial improvement amp resolution in many co-morbid

obesity conditions

ADVANTAGES OF RYGBP

1 Not reversible

2 Mortality 05- 1

3 Perioperative complications 5-10

4 Stricture of gastrojejunostomy-10 (long term)

5 Long term risk of protein amp vitamin deficiency and marginal ulceration of GJA

6Long term risk of intestinal obstruction ndash 2

LAPAROSCOPIC GASTRIC BYPASSCOMPLICATIONS

Biliopancreatic Diversion (BPD)

Primarily malabsorptive but restrictive component also

First Terminal ileum is measured to a length of 50 cms marked with suture

The alimentary tract beyond the proximal part of stomach is rearranged to

include only distal 200 cm of ileum including common channel

Common channel-Distal 50 cm of terminal ileum for absorption of fat and

protein

The proximal end of ileum anastomosed to proximal end of stomach after

performing distal hemigastrectomy

Biliopancreatic Diversion with Duodenal Switch

Modification to lessen high incidence of vit b12 deficiency anastomotic stricture at gastrojejunal anastomosis

This procedure involves a sleeve gastrectomy that is then diverted at the duodenum into the ileum at a point measured proximally from the ileocecal valve (usually 250 cm)

The distal duodenum and jejunum the biliopancreatic limb are then anastomosed to the ileum at a point measured proximally from the ileocecal valve (usually 100 cm)

Common channel is 100cm Entire alimentary tract is 250 cm This is the most aggressive bypass procedure commonly offered today Major difference-Sleeve gastrectomy instead of distal hemigastrectomy

bull Most women regained normal menstrual function and most had documented

spontaneous ovulation

bull Significant improvement in hirsutism androgen profiles and about a 50 reduction in

HOMA-IR

bull Follow up for more than 2 years showed that all women resumed normal menstrual

cycles HbA1C decreased from 82 to 51 in lt 3 months

bull 78 saw improvement in metabolic syndrome amp 48 showed improvement in PCOS

2 ROLE OF BARIATRIC SURGERY IN PCOS PATIENTS

bull Decrease menstrual irregularities bull PCOS women have less hyper androgenism

bull Sex hormone binding globulin increases bull LH and FSH levels have been reported to increase

bull Ovulatory function measured by luteal LH and Progesterone secretion improved bull Leptin levels decrease reflecting improved reproductive metabolic status

bull Subclinical hypothyroidism significantly reduced

THE SAFE TIMING OF PREGNANCYoptimal or minimal time gt12 months after bariatric surgery before becoming pregnant in order to allow the rapid weight loss and metabolic changes to subside

4 BARIATRIC SURGERY IN REPRODUCTIVE WOMEN

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)

The foregut hypothesis theory ndash 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

Effect of Bariatric Surgery on Diabetes Mellitus

Combined Gastric Restriction amp Malabsorption

Operative Risks (vs cholecystectomy)

Perioperative Mortality 1-2 vs 02-08 Early Complications 10 vs 29Late Complications 20 vs 1-2

LimitationsWidening of (unbanded) gastrojejunostomyExpansion of gastric pouch 25 with nearly 100 weight regainAdaptation of limb that receives the food

SUMMARY OF ALL TYPES OF SURGERY

bull LRYGBP ndash worlds best procedure 60-70 WL dumping syndrome malnutrition

bull LAGB- low complications varying range of wt loss frequent post-op visits ( 10)

bull DSBPD- more wt loss high complications good for high BMI gt 50 malabsorption +

bull VBG(vertical band gastroplasty) ndash longest available results good wt loss improved co-morbidities right for some ptsrisks too high to justify rewards

bull SG- needs long term research 1st step procedure low risks higher wt loss lesser complications pouch could Stretch over time long staple line could cause problems in future frequency is accelerating because of technical ease 1st stage procedure before bypass

Post-surgical Complications

Anastomosis leaks or staple line leaks Pulmonary Embolism or DVT Cholelithiasis Stomal ulceration Dumping syndrome Constipation

Anastamosis Leaks

Up to 7-10 days after surgery Most common at gastrojejunostomy enteroenterostomy Roux

limb stump staple line Can lead to peritonitis sepsis possible death Presentation

Tachycardia tachypnea Fever Ab painback pain Pelvic pressure or rebound tenderness

Anastamosis Leaks

Order Gastrograffin upper GI series Subclinical cases

Bowel rest Parenteral nutrition IV antibiotic if H pylori

Clinically suspect leak Laparoscopic evaluation and leak repair

Failure to evaluate is the most common cause of preventable major long-term disability or death in bariatric surgical patients

Pulmonary Embolism

Sudden cause of death up to one month after surgery 20-30 mortality rate High risk may have vena cava filter placement prior to surgery Prophylaxis with compression stockings and LMWH Early ambulation imperitive

Pulmonary Embolism

Presentation Profound hypoxia Hypotension Signs of sepsis

Immediate spiral chest CT Abdominal exploration if too large for machine No pathology start anticoagulation Too largehelliphellipNO SURGERY

Cholelithiasis

Up to 36 of patients within 6 months post-op Bile stasis leads to increased sludge and gallstones Prophylactic cholecystectomy prior to surgery if

evidence of existing sludge or stones Prevent post-operative disease with concurrent bariatric

surgery and cholecystectomy Prophylactic use of urosidol

Expensive and unpalatable

Stomal Ulceration

12-15 within 2-4 mos Post-surgery Etiology

Overabundant acid in pouch leads to excessive acid passing through stoma

Pouch tension and staple line breakdown NSAID use

Presentation Dyspepsia vomiting Epigastric or retrosternal pain

Stomal Ulceration

Treatment PPI carafate Antibiotics if H Pylori Avoid NSAIDS alcohol smoking

If no response to treatment Endoscopy Back to surgery for pouch revision or staple line repair

Dumping Syndrome

More than 15 patients Hypotention Tachycardia Lightheadedness syncope Flushing Abdominal cramping and diarrhea Nausea and vomiting

Dumping Syndrome

Occurs with high dose simple sugar ingestion Sugar in small intestine causes osmotic overload and fluid

shift from blood to intestine Increased intestinal volume leads to watery diarrhea Decreased blood volume leads to systemic changes Patient education

Eat slowly Avoid drinking before during and not until 30 minutes after meals

Constipation

Most common complaint Causes

Dehydration and decreased fluid intake post-operatively Increased metabolic water needs Calcium and iron supplement use following surgery

Treat with increased fluids and stool softeners

Nutritional Consequences

Iron deficiency anemia B12 deficiency Folate deficiency Calcium and Vitamin D deficiency

Not seen with purely restrictive surgeries

Iron deficiency and anemia

Common following RYGB As high as 49 of patients Multifactorial cause

Low gastric acid levels prohibit iron cleavage from food Absorption inhibited because no nutrient exposure to duodenum or

proximal jejunum Decrease in iron-rich food consumption due to intolerance

Treat with oral supplementation of ferrous sulfate or ferrous gluconate

Vitamin B12 deficiency

Up to 70 of patients Lack of hydrochloric acid and pepsin in stomach

Prevents B12 cleavage from food Affects secretion of intrinsic factor thus B12 absorption

Intolerance to meat and milk Oral supplementation usually adequate otherwise IM injections used

Folate Deficiency

40 of gastric bypass patients Complete absorption requires B12 Absorption dependent on HCl and upper 13 stomach Deficiency generally caused by decreased consumption Oral supplementation

Vitamin D and Calcium Deficiency

Vitamin D deficiency is common among obese people Calcium absorption decreased because duodenum is

bypassed Intolerance to dairy foods high in calcium Vitamin D is required for Ca++ absorption Prolonged deficiencies lead to

Bone resorption osteomalacia osteoporosis Treat with calcium citrate supplementation and 2 weekly

doses of Vitamin D

Nutritional Implications of Various Bariatric Surgeries(34)

bull RYGB Malabsorption of Vit B12 Vit B1 (thiamin) Vit D Vit K Folate Iron Calcium

bull LAGB Folic Acid deficiency

bull BPD and BPDDS Vit A D E and K deficiency Protein-Calorie Malnutrition Malabsorption of

Calcium Zinc Selenium Sodium Potassium Chloride Phosphorus Magnesium

Recommended Daily Supplements(4)

Multivitamin with iron (prenatal vitamin will have adeq amount of folic acid)

Calcium (citrate) with vitamin D (1200-1500 mg calcium with 800-1000 IU vitamin D)

Oral vitamin B12 (500-1000 mcg) Iron (65 mgday in elemental form)

Vitamin C (to increase absorption of Iron) Thiamin (10 mgday)

Diet Recommendations(3)

Reduce food volume Chew food very well Slow pace of eating No liquids with meals Encourage fruits and vegetables as diet progresses Include high protein foods (at least 60gday) may need protein

supplements

Diet Progression Gastric Bypass

Stage 1 Clear liquids and protein supplement (1 week)

Stage 2No concentrated sweets low fat puree diet ( 3 weeks)

Stage 3 Regular texture weight reduction diet

Diet Progression Lap - Band

Stage 1 Clear liquids and protein supplement ( 2 weeks)

Stage 2 No concentrated sweets low fat puree diet (2weeks)

Stage 3 Regular texture weight reduction diet

Stage 1

Only clear liquids allowed Avoid sweetened beverages Sip very slowly No straws Avoid caffeinated carbonated and alcoholic beverages STOP drinking if you feel fullness pain or discomfort

Protein supplements

Begin the day after you go home from Hospital

Minimum protein target 70gmsday

May use powder or pre-mixed liquid forms (Whey protein is preferred)

Protein pills may not be used

Vitamin and Mineral Supplements

Gastric bypass patients In addition to eating much less food gastric bypass patients will also

absorb vitamins and minerals differently after surgery They will require daily multivitamin calcium and iron

supplementation for the rest of your life

Vitamin and Mineral Supplements

Lap-Bandreg patients

Require a multivitamin with minerals daily

It may be necessary to take additional vitamins and minerals eg calcium iron folateB1 B12These will be prescribed as needed

Stage 2 dietPUREE

Puree diet

Regular scheduled meals Avoid meal skipping Plan meals in advance Eat Slowly Eat protein foods first Moisten meats Use liquid protein as supplement not as meal replacement

Measure 2 oz portions at each meal eating when full Separate liquids and solids No bread rice or pasta Avoid added sugars and high fat

foods VARIETY

Why SurgeryDiet and exercise are not effective

long term in the morbidly obese Surgery is an accepted and effective approach Medical co-morbidities are improvedresolved Increases life expectancy Decreases health care costs Surgical risk is acceptable vs risk of long-term obesity

RESOLUTION OF DISEASES FOLLOWING BARIATRIC SURGERY

Who Is a Surgical Candidate BMI gt 40 kgm2

-OR- BMI gt 35 kgm2 and major medical complications of

obesity-AND-

Failure of other approaches to long-term weight loss Age 18-55(relative)

Recommended BMI values for Bariatric Surgery in Asians

BMI ge 375

BMI ge 325 with two

associated co-

morbidities

No endocrine cause of obesity Acceptable operative risk Understands surgery and risks Absence of drug or alcohol problem No uncontrolled psychological conditions Consensus after bariatric team

evaluation SurgeonDieticianPsychologistConsultant

Dedicated to life-style change and follow-up

Obesity multidisciplinary team

Surgeon Physician Anesthetist Dietician Specialist bariatric nurse Skilled theatre staff Psychiatrist

Bariatric Surgery and Diabetes

International Diabetes Federation (2011) Journal of Diabetes (3(2011) 261-264) ldquoBariatric surgery is an appropriate treatment of people with T2D and

obesity who are not achieving recommended treatment targets with existing medical therapies especially in the presence of other major comorbiditiesrdquo

lt1 of those eligible actually have WLS for diabetes

Contraindications

Factors that may be considered contraindications include unstable CAD uncontrolled severe OSA uncontrolled psychiatric disorder mental retardation (IQ lt 60) inability to understand the surgery perceived inability to adhere to postoperative restrictions continued drug abuse malignancy with a poor 5-year survival prognosis Cirrhotic liver disease with portal hypertension

Preoperative EvaluationAttention should focus on issues unique to the obese patient

particularly cardiorespiratory status and the airwayConsideration of co morbidities ie hypertension diabetes heart

failure IHD obesity-hypoventilation syndrome metabolic syndrome etc

Results of the sleep study History of previous surgeries their anesthetic challenges need for

ICU admissionCurrent medicationsPatients scheduled for repeat bariatric surgery should be screened

preoperatively for long-term metabolic and nutritional abnormalities

Investigationshellip Recommended preoperative laboratory evaluations include

fasting blood glucose lipid profile electrolytes serum chemistries (to evaluate renal and hepatic function) complete blood count Serum ferritin vitamin B12 thyrotropin amp 25-hydroxyvitamin D

(Miller 7th edition- anesthesia for Bariatic Surgery) ABG measurements help evaluate ventilation as well as the need for perioperative oxygen administration and

postoperative ventilation Routine pulmonary function tests and liver function tests are not cost-effective in asymptomatic obese patients Coaugulation profile ( liver problem repeat surgery orlistat) ECG echocardiography Sleep study if suspected OSA

(Barash 6th edition anesthesia and obesity)

Concurrent Preoperative and Prophylactic Medications

Patients usual medications should be continued until the time of surgery with the possible exception of insulin and oral hypoglycemics

Antibiotic prophylaxis is usually indicated

Obesity itself does not increase the risk for aspiration acid aspiration prophylaxis including H2 receptor agonists or proton pump inhibitors must be considered in patients with identifiable risk for aspiration

Anxiolysis and prophylaxis against deep vein thrombosis (DVT) should be addressed at premedication

DVT consideration Morbid obesity is a major independent risk factor for sudden death from

acute postoperative pulmonary embolism Subcutaneous heparin 5000 IU administered before surgery and repeated every 8 to 12

hours until the patient is fully mobile reduces the risk of DVT LMWH can also be used

Preoperative prophylactic placement of an inferior vena cava filter should be considered in venous stasis disease BMI ge60 truncal obesity and OSA

What Are the Risks

MAJOR RISKS Death (1 of patients die within 30 days) Severe malnutrition (anemia PEM osteomalacia) Peritonitis (from leakage or ruptures at staple sites)

or other infection Obstructions caused by scar tissue in the stomach or

bowels

MINOR RISKS Dumping Syndrome (unpleasant but not harmful) Diarrhea and malodorous gas production Lactose intolerance Hair loss (short-term post-surgery) May have to eventually undergo surgical revision Pain post-surgery

History of Bariatric Surgery

Obesity surgery is not a new discipline The earliest Bariatric procedure performed was in 1954 at Minnesota The procedure

was Jejuno-ileal bypass In 1966Gastric Bypass was introduced as a surgical procedure for weight loss at the

University of Iowa In 1977Griffen reported the first Roux-en-Y Gastric Bypass In 1980surgeons with a more conservative approach developed the Vertical Banded

Gastroplasty Other procedures with longer intestinal segment bypass were also introduced such as

Biliopancreatic Diversions These complex procedures are recommended in super-obese patients ie BMIgt60

How does surgery work

RESTRICTIVE - RESTRICT AMOUNT OF FOOD INGESTED Decreases appetitehunger

Early satiety Behavior modification Gastric Banding (Lap Band)

Roux-en Y Gastric bypass (RYGB) Sleeve Gastrectomy

MALABSORPTIVE- LIMITS DIGESTION AND ABSORPTION Decreases length of intestine exposed to digested food

25 of fat is absorbed Behavior modification

Biliopancreatic Diversion Duodenal Switch (BPDDS)

ALL OPERATIONS CAN BE PERFORMED OPEN OR LAPAROSCOPICALLY

Laparoscopic vs Open

OPEN uarr post op pain Longer hospitalizations uarr wound complications

Infection Hernias Seromas

Return to work in 4-8 weeks

LAPAROSCOPIC darr post op pain Early mobility darr Wound complications 2-3 day hospital stay Return to work in 1-3 weeks

1 Nguyen NT et al Accelerated growth of bariatric surgery with the introduction of minimally invasive surgery Arch Surg 20051401198-202

Procedures that are solely restrictive by creating a small gastric pouch of volume 15 to 30 cc amp a degree of outlet obstruction leading to delayed gastric emptying The goal is to reduce oral intake by limiting gastric volume produce early satiety and leave the alimentary canal in continuity minimizing the risks of metabolic complications

1VERTICAL BANDED GASTROPLASTY

2ADJUSTABLE GASTRIC BANDING (LAGB )

3 SLEEVE GASTRECTOMY

4GASTRIC PLICATION

5 INTRA GASTRIC BALLOON (GASTRIC BALLOON)

RESTRICTIVE PROCEDURES

Malabsorption is achieved by creating a short gut syndrome andor by accomplishing distal mixing of bile and pancreatic juice with ingested nutrients thereby reducing absorption Some purely malabsorptive operations are no longer recommended due to their potential hazard to cause serious nutritional deficiencies

1 BILIOPANCREATIC DIVERSION2 THE JEJUNAL-ILEAL BYPASS3 ENDOLUMINAL SLEEVE

MALABSORPTIVE PROCEDURES

MIXED PROCEDURES

1GASTRIC BYPASS ROUX-EN-Y ( RYGBP)

2SLEEVE GASTRECTOMY WITH DUODENAL SWITCH

3IMPLANTABLE 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

The stomach is partitioned along its axis with a non-

adjustable poly-urethane band and with linear amp 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 was practiced in 1980

Vertical Banded Gastroplasty (VBG)

ADJUSTABLE GASTRIC BANDING (LAP BAND SURGERY LAGB)

Restrictive Procedure The procedure was first performed by Cadiere in 1992 but was made popular by Belachew and Legrand in 1993 An inflatable silicone BAND is placed around the top portion of the stomach to form a small stomach pouch amp sewed

This band is connected to a tube that leads to a port above the abdominal muscles placed below the skin (FILL ndash PORT)

During follow up visits we inject or remove saline solution to make the band tighter or looser

Adjustable Gastric Band

bull 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

How does the Band work

Surgery Factors Restriction of meal size Decreased appetite

Patient Factors Decreased calorie intake Increased calorie expenditure

LAP-BAND Adjustability

Unfilled Band Filled Band

Adjustments are made in the office

Complications of Gastric Lap-Band

bull Perforation of Stomachbull Slippagebull Gastric Erosion(much less after Pars flaccida technique) bull Dilated Esophagusbull Tubing access port problemsbull Mal positioningbull Abdominal Painbull Heartburnbull Vomitingbull Inability to Adjust the Bandbull Failure to Lose Weightbull Infection of Systembull Fatigue or malfunction

Advantages

No intestinal surgery No staplingcutting of stomach No nutritional risks Adjustable Reversible Safe

Foreign body Frequent follow-up visits Needs more commitment Easy to cheat

Disadvantages

Comparison of Adjustable Gastric Banding and Vertical Banded Gastroplasty

Laparoscopic adjustable gastric banding Reversible Adjustable Simpler to perform laparoscopically Sustained weight loss of gt50 EBW gt5

years following surgery Complications Gastric prolapse band

erosion rarely gastric perforation and access port complications

Vertical banded gastroplasty Irreversible Non adjustable Technically difficult by laparoscopy Weight loss of 25-50 EBW and weight gain

after 2-3 years Complications suture line disruption gastric

leak weight gain

>

>

Originally used as the first-stage operation for a proposed biliopancreatic diversion with duodenal switch in high-risk patients

The sleeve gastrectomy has caught on as a primary obesity treatment as surgeons are reporting weight loss of 55 of excess body weight past 5 years in some patients

The sleeve gastrectomy is also known as the greater curvature gastrectomy vertical or longitudinal gastrectomy or Pylorus preserving lsquogastric tube creationrsquo

Rapid and less traumatic operation Good resolution of co-morbidities and good weight loss

A further second surgical step is then easily feasible if necessary

SLEEVE GASTRECTOMY

SLEEVE GASTRECTOMY

A sleeve gastrectomy involves resection of

approximately 80 of the greater curvature

side of the stomach

Smaller tubular gastric ldquosleeverdquo created

along the lesser curve that is based on the

lesser curvature blood supply

Ideal approximate capacity of the stomach

after the procedure is about 30- 60 ml pouch

1MECHANICAL RESTRICTION by reducing the volume of the stomach and impairing stomach mobility Also called lsquoFood limitingrsquo operation

2HORMONAL MODIFICATION by removing a great part of the Ghrelin (Hunger Hormone) production tissue

(Ghrelin is a 28 amino-acid-peptide secreted by the oxyntic glands of the gastric fungus It is a potent orexigenic (appetite-stimulating) peptide mediated by the activation of its receptors in the hypothalamus or pituitary area)

The gastric fundus contains 10 to 20 times more ghrelin per one gram of tissue than the duodenum In the SG resection of the fundus removes the major portion of ghrelin release therefore appetite decreases

The sleeve gastrectomy (SG) induces weight loss by 2 mechanisms

>

Intragastric balloon involves placing a deflated balloon into the stomach and then filling it to decrease the amount of gastric space

The balloon can be left in the stomach for a maximum of 6 months and results in an average weight loss of 5ndash9 BMI over half a year

Done endoscopically

The intragastric balloon may be used prior to another bariatric surgery as a step-down procedure

INTRA GASTRIC BALLOON

>

>

The EndoBarrier gastrointestinal liner mimics the effects of gastric bypass surgery

Itrsquos designed to work by inserting a flexible

tube-like barrier into the duodenum amp 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

ENDO BARRIER LINER SYSTEM

B MAL- ABSORPTIVE PROCEDURES

Malabsorptive surgeries rearrange andor remove part of digestive system which then limits the amount of calories and nutrients that body can absorb Treatment with a large malabsorptive component results in the most weight loss but tend to have slightly higher complication rates

1JEJUNAL ILEAL BYPASS ndash no longer performed for high complication rates

2ILEAL TRANSPOSITION- New malabsoptive procedure on trial for treatment of DM type 2 and metabolic disorders

C COMBINATION PROCEDURES RESTRICTIVE + MALABSORBTIVE

1LAP GASTRIC BYPASS ndash ROUX-EN- Y ndash more malabsorption than the restrictive

2MINI- GASTRIC BYPASS- mainly restrictive

3DUODENAL SWITCH ndash the sleeve stomach is the restrictive portion ampthe intestinal bypass (duodenal switch) is the malabsorptive component

When surgery combines both restrictive and malabsorptive techniques it is know as a ldquocombinationrdquo procedure Most types of bariatric surgery carry at least a small element of both components but the following surgeries achieve a notable portion of weight loss from eachhellip

1 LAP GASTRIC BYPASS LGB

The Roux-en-Y gastric bypass(known simply as the LRYGBP) is the most commonly performed procedure

It primarily causesweight loss by restricting thefood intake however there ismore amount of mal absorption that occurs with this operation

GASTRIC BYPASS LRYGBP

bullThe stomach is stapled into2 pieces one small and one large The small piece becomes the ldquonewrdquo stomach pouch

bull The larger portion of the stomach stays in place however will lie dormant for the remainder of the patientrsquos life

GASTRIC BYPASS LGB

bull The small intestine (the jejunum) is divided using a surgical staplerApprox 50-70 cm from the DJ Junction

GASTRIC BYPASS LGB

Y- LIMB BP LIMB

bull The end of the Roux limb is then attached to the newly formed stomach pouch which carries food to the distal intestine

bull The Roux loop is completed by forming a jejunostomy

bull The Y limb or BPD limb carries digestive juices from the pancreas gall bladder liver and duodenum to the intestines

bull The food and the digestive juices mix where the Roux limb and Y limb meet much below say 100-150 cm from DJ

Roux limb or alimentary limb

100-150 cm

How Does the Roux-en-Y Work

Surgery factors restriction of meal size ldquodumping syndromerdquo some malabsorption decreased appetite

Patient factors calorie intake calorie expenditure

bull Most commonly performedbull Most reliable operation for long term weight lossbull Long term weight loss averages 60 to 75 percent of EBWbull Malnutrition is unusualbull Substantial improvement amp resolution in many co-morbid

obesity conditions

ADVANTAGES OF RYGBP

1 Not reversible

2 Mortality 05- 1

3 Perioperative complications 5-10

4 Stricture of gastrojejunostomy-10 (long term)

5 Long term risk of protein amp vitamin deficiency and marginal ulceration of GJA

6Long term risk of intestinal obstruction ndash 2

LAPAROSCOPIC GASTRIC BYPASSCOMPLICATIONS

Biliopancreatic Diversion (BPD)

Primarily malabsorptive but restrictive component also

First Terminal ileum is measured to a length of 50 cms marked with suture

The alimentary tract beyond the proximal part of stomach is rearranged to

include only distal 200 cm of ileum including common channel

Common channel-Distal 50 cm of terminal ileum for absorption of fat and

protein

The proximal end of ileum anastomosed to proximal end of stomach after

performing distal hemigastrectomy

Biliopancreatic Diversion with Duodenal Switch

Modification to lessen high incidence of vit b12 deficiency anastomotic stricture at gastrojejunal anastomosis

This procedure involves a sleeve gastrectomy that is then diverted at the duodenum into the ileum at a point measured proximally from the ileocecal valve (usually 250 cm)

The distal duodenum and jejunum the biliopancreatic limb are then anastomosed to the ileum at a point measured proximally from the ileocecal valve (usually 100 cm)

Common channel is 100cm Entire alimentary tract is 250 cm This is the most aggressive bypass procedure commonly offered today Major difference-Sleeve gastrectomy instead of distal hemigastrectomy

bull Most women regained normal menstrual function and most had documented

spontaneous ovulation

bull Significant improvement in hirsutism androgen profiles and about a 50 reduction in

HOMA-IR

bull Follow up for more than 2 years showed that all women resumed normal menstrual

cycles HbA1C decreased from 82 to 51 in lt 3 months

bull 78 saw improvement in metabolic syndrome amp 48 showed improvement in PCOS

2 ROLE OF BARIATRIC SURGERY IN PCOS PATIENTS

bull Decrease menstrual irregularities bull PCOS women have less hyper androgenism

bull Sex hormone binding globulin increases bull LH and FSH levels have been reported to increase

bull Ovulatory function measured by luteal LH and Progesterone secretion improved bull Leptin levels decrease reflecting improved reproductive metabolic status

bull Subclinical hypothyroidism significantly reduced

THE SAFE TIMING OF PREGNANCYoptimal or minimal time gt12 months after bariatric surgery before becoming pregnant in order to allow the rapid weight loss and metabolic changes to subside

4 BARIATRIC SURGERY IN REPRODUCTIVE WOMEN

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)

The foregut hypothesis theory ndash 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

Effect of Bariatric Surgery on Diabetes Mellitus

Combined Gastric Restriction amp Malabsorption

Operative Risks (vs cholecystectomy)

Perioperative Mortality 1-2 vs 02-08 Early Complications 10 vs 29Late Complications 20 vs 1-2

LimitationsWidening of (unbanded) gastrojejunostomyExpansion of gastric pouch 25 with nearly 100 weight regainAdaptation of limb that receives the food

SUMMARY OF ALL TYPES OF SURGERY

bull LRYGBP ndash worlds best procedure 60-70 WL dumping syndrome malnutrition

bull LAGB- low complications varying range of wt loss frequent post-op visits ( 10)

bull DSBPD- more wt loss high complications good for high BMI gt 50 malabsorption +

bull VBG(vertical band gastroplasty) ndash longest available results good wt loss improved co-morbidities right for some ptsrisks too high to justify rewards

bull SG- needs long term research 1st step procedure low risks higher wt loss lesser complications pouch could Stretch over time long staple line could cause problems in future frequency is accelerating because of technical ease 1st stage procedure before bypass

Post-surgical Complications

Anastomosis leaks or staple line leaks Pulmonary Embolism or DVT Cholelithiasis Stomal ulceration Dumping syndrome Constipation

Anastamosis Leaks

Up to 7-10 days after surgery Most common at gastrojejunostomy enteroenterostomy Roux

limb stump staple line Can lead to peritonitis sepsis possible death Presentation

Tachycardia tachypnea Fever Ab painback pain Pelvic pressure or rebound tenderness

Anastamosis Leaks

Order Gastrograffin upper GI series Subclinical cases

Bowel rest Parenteral nutrition IV antibiotic if H pylori

Clinically suspect leak Laparoscopic evaluation and leak repair

Failure to evaluate is the most common cause of preventable major long-term disability or death in bariatric surgical patients

Pulmonary Embolism

Sudden cause of death up to one month after surgery 20-30 mortality rate High risk may have vena cava filter placement prior to surgery Prophylaxis with compression stockings and LMWH Early ambulation imperitive

Pulmonary Embolism

Presentation Profound hypoxia Hypotension Signs of sepsis

Immediate spiral chest CT Abdominal exploration if too large for machine No pathology start anticoagulation Too largehelliphellipNO SURGERY

Cholelithiasis

Up to 36 of patients within 6 months post-op Bile stasis leads to increased sludge and gallstones Prophylactic cholecystectomy prior to surgery if

evidence of existing sludge or stones Prevent post-operative disease with concurrent bariatric

surgery and cholecystectomy Prophylactic use of urosidol

Expensive and unpalatable

Stomal Ulceration

12-15 within 2-4 mos Post-surgery Etiology

Overabundant acid in pouch leads to excessive acid passing through stoma

Pouch tension and staple line breakdown NSAID use

Presentation Dyspepsia vomiting Epigastric or retrosternal pain

Stomal Ulceration

Treatment PPI carafate Antibiotics if H Pylori Avoid NSAIDS alcohol smoking

If no response to treatment Endoscopy Back to surgery for pouch revision or staple line repair

Dumping Syndrome

More than 15 patients Hypotention Tachycardia Lightheadedness syncope Flushing Abdominal cramping and diarrhea Nausea and vomiting

Dumping Syndrome

Occurs with high dose simple sugar ingestion Sugar in small intestine causes osmotic overload and fluid

shift from blood to intestine Increased intestinal volume leads to watery diarrhea Decreased blood volume leads to systemic changes Patient education

Eat slowly Avoid drinking before during and not until 30 minutes after meals

Constipation

Most common complaint Causes

Dehydration and decreased fluid intake post-operatively Increased metabolic water needs Calcium and iron supplement use following surgery

Treat with increased fluids and stool softeners

Nutritional Consequences

Iron deficiency anemia B12 deficiency Folate deficiency Calcium and Vitamin D deficiency

Not seen with purely restrictive surgeries

Iron deficiency and anemia

Common following RYGB As high as 49 of patients Multifactorial cause

Low gastric acid levels prohibit iron cleavage from food Absorption inhibited because no nutrient exposure to duodenum or

proximal jejunum Decrease in iron-rich food consumption due to intolerance

Treat with oral supplementation of ferrous sulfate or ferrous gluconate

Vitamin B12 deficiency

Up to 70 of patients Lack of hydrochloric acid and pepsin in stomach

Prevents B12 cleavage from food Affects secretion of intrinsic factor thus B12 absorption

Intolerance to meat and milk Oral supplementation usually adequate otherwise IM injections used

Folate Deficiency

40 of gastric bypass patients Complete absorption requires B12 Absorption dependent on HCl and upper 13 stomach Deficiency generally caused by decreased consumption Oral supplementation

Vitamin D and Calcium Deficiency

Vitamin D deficiency is common among obese people Calcium absorption decreased because duodenum is

bypassed Intolerance to dairy foods high in calcium Vitamin D is required for Ca++ absorption Prolonged deficiencies lead to

Bone resorption osteomalacia osteoporosis Treat with calcium citrate supplementation and 2 weekly

doses of Vitamin D

Nutritional Implications of Various Bariatric Surgeries(34)

bull RYGB Malabsorption of Vit B12 Vit B1 (thiamin) Vit D Vit K Folate Iron Calcium

bull LAGB Folic Acid deficiency

bull BPD and BPDDS Vit A D E and K deficiency Protein-Calorie Malnutrition Malabsorption of

Calcium Zinc Selenium Sodium Potassium Chloride Phosphorus Magnesium

Recommended Daily Supplements(4)

Multivitamin with iron (prenatal vitamin will have adeq amount of folic acid)

Calcium (citrate) with vitamin D (1200-1500 mg calcium with 800-1000 IU vitamin D)

Oral vitamin B12 (500-1000 mcg) Iron (65 mgday in elemental form)

Vitamin C (to increase absorption of Iron) Thiamin (10 mgday)

Diet Recommendations(3)

Reduce food volume Chew food very well Slow pace of eating No liquids with meals Encourage fruits and vegetables as diet progresses Include high protein foods (at least 60gday) may need protein

supplements

Diet Progression Gastric Bypass

Stage 1 Clear liquids and protein supplement (1 week)

Stage 2No concentrated sweets low fat puree diet ( 3 weeks)

Stage 3 Regular texture weight reduction diet

Diet Progression Lap - Band

Stage 1 Clear liquids and protein supplement ( 2 weeks)

Stage 2 No concentrated sweets low fat puree diet (2weeks)

Stage 3 Regular texture weight reduction diet

Stage 1

Only clear liquids allowed Avoid sweetened beverages Sip very slowly No straws Avoid caffeinated carbonated and alcoholic beverages STOP drinking if you feel fullness pain or discomfort

Protein supplements

Begin the day after you go home from Hospital

Minimum protein target 70gmsday

May use powder or pre-mixed liquid forms (Whey protein is preferred)

Protein pills may not be used

Vitamin and Mineral Supplements

Gastric bypass patients In addition to eating much less food gastric bypass patients will also

absorb vitamins and minerals differently after surgery They will require daily multivitamin calcium and iron

supplementation for the rest of your life

Vitamin and Mineral Supplements

Lap-Bandreg patients

Require a multivitamin with minerals daily

It may be necessary to take additional vitamins and minerals eg calcium iron folateB1 B12These will be prescribed as needed

Stage 2 dietPUREE

Puree diet

Regular scheduled meals Avoid meal skipping Plan meals in advance Eat Slowly Eat protein foods first Moisten meats Use liquid protein as supplement not as meal replacement

Measure 2 oz portions at each meal eating when full Separate liquids and solids No bread rice or pasta Avoid added sugars and high fat

foods VARIETY

RESOLUTION OF DISEASES FOLLOWING BARIATRIC SURGERY

Who Is a Surgical Candidate BMI gt 40 kgm2

-OR- BMI gt 35 kgm2 and major medical complications of

obesity-AND-

Failure of other approaches to long-term weight loss Age 18-55(relative)

Recommended BMI values for Bariatric Surgery in Asians

BMI ge 375

BMI ge 325 with two

associated co-

morbidities

No endocrine cause of obesity Acceptable operative risk Understands surgery and risks Absence of drug or alcohol problem No uncontrolled psychological conditions Consensus after bariatric team

evaluation SurgeonDieticianPsychologistConsultant

Dedicated to life-style change and follow-up

Obesity multidisciplinary team

Surgeon Physician Anesthetist Dietician Specialist bariatric nurse Skilled theatre staff Psychiatrist

Bariatric Surgery and Diabetes

International Diabetes Federation (2011) Journal of Diabetes (3(2011) 261-264) ldquoBariatric surgery is an appropriate treatment of people with T2D and

obesity who are not achieving recommended treatment targets with existing medical therapies especially in the presence of other major comorbiditiesrdquo

lt1 of those eligible actually have WLS for diabetes

Contraindications

Factors that may be considered contraindications include unstable CAD uncontrolled severe OSA uncontrolled psychiatric disorder mental retardation (IQ lt 60) inability to understand the surgery perceived inability to adhere to postoperative restrictions continued drug abuse malignancy with a poor 5-year survival prognosis Cirrhotic liver disease with portal hypertension

Preoperative EvaluationAttention should focus on issues unique to the obese patient

particularly cardiorespiratory status and the airwayConsideration of co morbidities ie hypertension diabetes heart

failure IHD obesity-hypoventilation syndrome metabolic syndrome etc

Results of the sleep study History of previous surgeries their anesthetic challenges need for

ICU admissionCurrent medicationsPatients scheduled for repeat bariatric surgery should be screened

preoperatively for long-term metabolic and nutritional abnormalities

Investigationshellip Recommended preoperative laboratory evaluations include

fasting blood glucose lipid profile electrolytes serum chemistries (to evaluate renal and hepatic function) complete blood count Serum ferritin vitamin B12 thyrotropin amp 25-hydroxyvitamin D

(Miller 7th edition- anesthesia for Bariatic Surgery) ABG measurements help evaluate ventilation as well as the need for perioperative oxygen administration and

postoperative ventilation Routine pulmonary function tests and liver function tests are not cost-effective in asymptomatic obese patients Coaugulation profile ( liver problem repeat surgery orlistat) ECG echocardiography Sleep study if suspected OSA

(Barash 6th edition anesthesia and obesity)

Concurrent Preoperative and Prophylactic Medications

Patients usual medications should be continued until the time of surgery with the possible exception of insulin and oral hypoglycemics

Antibiotic prophylaxis is usually indicated

Obesity itself does not increase the risk for aspiration acid aspiration prophylaxis including H2 receptor agonists or proton pump inhibitors must be considered in patients with identifiable risk for aspiration

Anxiolysis and prophylaxis against deep vein thrombosis (DVT) should be addressed at premedication

DVT consideration Morbid obesity is a major independent risk factor for sudden death from

acute postoperative pulmonary embolism Subcutaneous heparin 5000 IU administered before surgery and repeated every 8 to 12

hours until the patient is fully mobile reduces the risk of DVT LMWH can also be used

Preoperative prophylactic placement of an inferior vena cava filter should be considered in venous stasis disease BMI ge60 truncal obesity and OSA

What Are the Risks

MAJOR RISKS Death (1 of patients die within 30 days) Severe malnutrition (anemia PEM osteomalacia) Peritonitis (from leakage or ruptures at staple sites)

or other infection Obstructions caused by scar tissue in the stomach or

bowels

MINOR RISKS Dumping Syndrome (unpleasant but not harmful) Diarrhea and malodorous gas production Lactose intolerance Hair loss (short-term post-surgery) May have to eventually undergo surgical revision Pain post-surgery

History of Bariatric Surgery

Obesity surgery is not a new discipline The earliest Bariatric procedure performed was in 1954 at Minnesota The procedure

was Jejuno-ileal bypass In 1966Gastric Bypass was introduced as a surgical procedure for weight loss at the

University of Iowa In 1977Griffen reported the first Roux-en-Y Gastric Bypass In 1980surgeons with a more conservative approach developed the Vertical Banded

Gastroplasty Other procedures with longer intestinal segment bypass were also introduced such as

Biliopancreatic Diversions These complex procedures are recommended in super-obese patients ie BMIgt60

How does surgery work

RESTRICTIVE - RESTRICT AMOUNT OF FOOD INGESTED Decreases appetitehunger

Early satiety Behavior modification Gastric Banding (Lap Band)

Roux-en Y Gastric bypass (RYGB) Sleeve Gastrectomy

MALABSORPTIVE- LIMITS DIGESTION AND ABSORPTION Decreases length of intestine exposed to digested food

25 of fat is absorbed Behavior modification

Biliopancreatic Diversion Duodenal Switch (BPDDS)

ALL OPERATIONS CAN BE PERFORMED OPEN OR LAPAROSCOPICALLY

Laparoscopic vs Open

OPEN uarr post op pain Longer hospitalizations uarr wound complications

Infection Hernias Seromas

Return to work in 4-8 weeks

LAPAROSCOPIC darr post op pain Early mobility darr Wound complications 2-3 day hospital stay Return to work in 1-3 weeks

1 Nguyen NT et al Accelerated growth of bariatric surgery with the introduction of minimally invasive surgery Arch Surg 20051401198-202

Procedures that are solely restrictive by creating a small gastric pouch of volume 15 to 30 cc amp a degree of outlet obstruction leading to delayed gastric emptying The goal is to reduce oral intake by limiting gastric volume produce early satiety and leave the alimentary canal in continuity minimizing the risks of metabolic complications

1VERTICAL BANDED GASTROPLASTY

2ADJUSTABLE GASTRIC BANDING (LAGB )

3 SLEEVE GASTRECTOMY

4GASTRIC PLICATION

5 INTRA GASTRIC BALLOON (GASTRIC BALLOON)

RESTRICTIVE PROCEDURES

Malabsorption is achieved by creating a short gut syndrome andor by accomplishing distal mixing of bile and pancreatic juice with ingested nutrients thereby reducing absorption Some purely malabsorptive operations are no longer recommended due to their potential hazard to cause serious nutritional deficiencies

1 BILIOPANCREATIC DIVERSION2 THE JEJUNAL-ILEAL BYPASS3 ENDOLUMINAL SLEEVE

MALABSORPTIVE PROCEDURES

MIXED PROCEDURES

1GASTRIC BYPASS ROUX-EN-Y ( RYGBP)

2SLEEVE GASTRECTOMY WITH DUODENAL SWITCH

3IMPLANTABLE 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

The stomach is partitioned along its axis with a non-

adjustable poly-urethane band and with linear amp 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 was practiced in 1980

Vertical Banded Gastroplasty (VBG)

ADJUSTABLE GASTRIC BANDING (LAP BAND SURGERY LAGB)

Restrictive Procedure The procedure was first performed by Cadiere in 1992 but was made popular by Belachew and Legrand in 1993 An inflatable silicone BAND is placed around the top portion of the stomach to form a small stomach pouch amp sewed

This band is connected to a tube that leads to a port above the abdominal muscles placed below the skin (FILL ndash PORT)

During follow up visits we inject or remove saline solution to make the band tighter or looser

Adjustable Gastric Band

bull 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

How does the Band work

Surgery Factors Restriction of meal size Decreased appetite

Patient Factors Decreased calorie intake Increased calorie expenditure

LAP-BAND Adjustability

Unfilled Band Filled Band

Adjustments are made in the office

Complications of Gastric Lap-Band

bull Perforation of Stomachbull Slippagebull Gastric Erosion(much less after Pars flaccida technique) bull Dilated Esophagusbull Tubing access port problemsbull Mal positioningbull Abdominal Painbull Heartburnbull Vomitingbull Inability to Adjust the Bandbull Failure to Lose Weightbull Infection of Systembull Fatigue or malfunction

Advantages

No intestinal surgery No staplingcutting of stomach No nutritional risks Adjustable Reversible Safe

Foreign body Frequent follow-up visits Needs more commitment Easy to cheat

Disadvantages

Comparison of Adjustable Gastric Banding and Vertical Banded Gastroplasty

Laparoscopic adjustable gastric banding Reversible Adjustable Simpler to perform laparoscopically Sustained weight loss of gt50 EBW gt5

years following surgery Complications Gastric prolapse band

erosion rarely gastric perforation and access port complications

Vertical banded gastroplasty Irreversible Non adjustable Technically difficult by laparoscopy Weight loss of 25-50 EBW and weight gain

after 2-3 years Complications suture line disruption gastric

leak weight gain

>

>

Originally used as the first-stage operation for a proposed biliopancreatic diversion with duodenal switch in high-risk patients

The sleeve gastrectomy has caught on as a primary obesity treatment as surgeons are reporting weight loss of 55 of excess body weight past 5 years in some patients

The sleeve gastrectomy is also known as the greater curvature gastrectomy vertical or longitudinal gastrectomy or Pylorus preserving lsquogastric tube creationrsquo

Rapid and less traumatic operation Good resolution of co-morbidities and good weight loss

A further second surgical step is then easily feasible if necessary

SLEEVE GASTRECTOMY

SLEEVE GASTRECTOMY

A sleeve gastrectomy involves resection of

approximately 80 of the greater curvature

side of the stomach

Smaller tubular gastric ldquosleeverdquo created

along the lesser curve that is based on the

lesser curvature blood supply

Ideal approximate capacity of the stomach

after the procedure is about 30- 60 ml pouch

1MECHANICAL RESTRICTION by reducing the volume of the stomach and impairing stomach mobility Also called lsquoFood limitingrsquo operation

2HORMONAL MODIFICATION by removing a great part of the Ghrelin (Hunger Hormone) production tissue

(Ghrelin is a 28 amino-acid-peptide secreted by the oxyntic glands of the gastric fungus It is a potent orexigenic (appetite-stimulating) peptide mediated by the activation of its receptors in the hypothalamus or pituitary area)

The gastric fundus contains 10 to 20 times more ghrelin per one gram of tissue than the duodenum In the SG resection of the fundus removes the major portion of ghrelin release therefore appetite decreases

The sleeve gastrectomy (SG) induces weight loss by 2 mechanisms

>

Intragastric balloon involves placing a deflated balloon into the stomach and then filling it to decrease the amount of gastric space

The balloon can be left in the stomach for a maximum of 6 months and results in an average weight loss of 5ndash9 BMI over half a year

Done endoscopically

The intragastric balloon may be used prior to another bariatric surgery as a step-down procedure

INTRA GASTRIC BALLOON

>

>

The EndoBarrier gastrointestinal liner mimics the effects of gastric bypass surgery

Itrsquos designed to work by inserting a flexible

tube-like barrier into the duodenum amp 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

ENDO BARRIER LINER SYSTEM

B MAL- ABSORPTIVE PROCEDURES

Malabsorptive surgeries rearrange andor remove part of digestive system which then limits the amount of calories and nutrients that body can absorb Treatment with a large malabsorptive component results in the most weight loss but tend to have slightly higher complication rates

1JEJUNAL ILEAL BYPASS ndash no longer performed for high complication rates

2ILEAL TRANSPOSITION- New malabsoptive procedure on trial for treatment of DM type 2 and metabolic disorders

C COMBINATION PROCEDURES RESTRICTIVE + MALABSORBTIVE

1LAP GASTRIC BYPASS ndash ROUX-EN- Y ndash more malabsorption than the restrictive

2MINI- GASTRIC BYPASS- mainly restrictive

3DUODENAL SWITCH ndash the sleeve stomach is the restrictive portion ampthe intestinal bypass (duodenal switch) is the malabsorptive component

When surgery combines both restrictive and malabsorptive techniques it is know as a ldquocombinationrdquo procedure Most types of bariatric surgery carry at least a small element of both components but the following surgeries achieve a notable portion of weight loss from eachhellip

1 LAP GASTRIC BYPASS LGB

The Roux-en-Y gastric bypass(known simply as the LRYGBP) is the most commonly performed procedure

It primarily causesweight loss by restricting thefood intake however there ismore amount of mal absorption that occurs with this operation

GASTRIC BYPASS LRYGBP

bullThe stomach is stapled into2 pieces one small and one large The small piece becomes the ldquonewrdquo stomach pouch

bull The larger portion of the stomach stays in place however will lie dormant for the remainder of the patientrsquos life

GASTRIC BYPASS LGB

bull The small intestine (the jejunum) is divided using a surgical staplerApprox 50-70 cm from the DJ Junction

GASTRIC BYPASS LGB

Y- LIMB BP LIMB

bull The end of the Roux limb is then attached to the newly formed stomach pouch which carries food to the distal intestine

bull The Roux loop is completed by forming a jejunostomy

bull The Y limb or BPD limb carries digestive juices from the pancreas gall bladder liver and duodenum to the intestines

bull The food and the digestive juices mix where the Roux limb and Y limb meet much below say 100-150 cm from DJ

Roux limb or alimentary limb

100-150 cm

How Does the Roux-en-Y Work

Surgery factors restriction of meal size ldquodumping syndromerdquo some malabsorption decreased appetite

Patient factors calorie intake calorie expenditure

bull Most commonly performedbull Most reliable operation for long term weight lossbull Long term weight loss averages 60 to 75 percent of EBWbull Malnutrition is unusualbull Substantial improvement amp resolution in many co-morbid

obesity conditions

ADVANTAGES OF RYGBP

1 Not reversible

2 Mortality 05- 1

3 Perioperative complications 5-10

4 Stricture of gastrojejunostomy-10 (long term)

5 Long term risk of protein amp vitamin deficiency and marginal ulceration of GJA

6Long term risk of intestinal obstruction ndash 2

LAPAROSCOPIC GASTRIC BYPASSCOMPLICATIONS

Biliopancreatic Diversion (BPD)

Primarily malabsorptive but restrictive component also

First Terminal ileum is measured to a length of 50 cms marked with suture

The alimentary tract beyond the proximal part of stomach is rearranged to

include only distal 200 cm of ileum including common channel

Common channel-Distal 50 cm of terminal ileum for absorption of fat and

protein

The proximal end of ileum anastomosed to proximal end of stomach after

performing distal hemigastrectomy

Biliopancreatic Diversion with Duodenal Switch

Modification to lessen high incidence of vit b12 deficiency anastomotic stricture at gastrojejunal anastomosis

This procedure involves a sleeve gastrectomy that is then diverted at the duodenum into the ileum at a point measured proximally from the ileocecal valve (usually 250 cm)

The distal duodenum and jejunum the biliopancreatic limb are then anastomosed to the ileum at a point measured proximally from the ileocecal valve (usually 100 cm)

Common channel is 100cm Entire alimentary tract is 250 cm This is the most aggressive bypass procedure commonly offered today Major difference-Sleeve gastrectomy instead of distal hemigastrectomy

bull Most women regained normal menstrual function and most had documented

spontaneous ovulation

bull Significant improvement in hirsutism androgen profiles and about a 50 reduction in

HOMA-IR

bull Follow up for more than 2 years showed that all women resumed normal menstrual

cycles HbA1C decreased from 82 to 51 in lt 3 months

bull 78 saw improvement in metabolic syndrome amp 48 showed improvement in PCOS

2 ROLE OF BARIATRIC SURGERY IN PCOS PATIENTS

bull Decrease menstrual irregularities bull PCOS women have less hyper androgenism

bull Sex hormone binding globulin increases bull LH and FSH levels have been reported to increase

bull Ovulatory function measured by luteal LH and Progesterone secretion improved bull Leptin levels decrease reflecting improved reproductive metabolic status

bull Subclinical hypothyroidism significantly reduced

THE SAFE TIMING OF PREGNANCYoptimal or minimal time gt12 months after bariatric surgery before becoming pregnant in order to allow the rapid weight loss and metabolic changes to subside

4 BARIATRIC SURGERY IN REPRODUCTIVE WOMEN

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)

The foregut hypothesis theory ndash 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

Effect of Bariatric Surgery on Diabetes Mellitus

Combined Gastric Restriction amp Malabsorption

Operative Risks (vs cholecystectomy)

Perioperative Mortality 1-2 vs 02-08 Early Complications 10 vs 29Late Complications 20 vs 1-2

LimitationsWidening of (unbanded) gastrojejunostomyExpansion of gastric pouch 25 with nearly 100 weight regainAdaptation of limb that receives the food

SUMMARY OF ALL TYPES OF SURGERY

bull LRYGBP ndash worlds best procedure 60-70 WL dumping syndrome malnutrition

bull LAGB- low complications varying range of wt loss frequent post-op visits ( 10)

bull DSBPD- more wt loss high complications good for high BMI gt 50 malabsorption +

bull VBG(vertical band gastroplasty) ndash longest available results good wt loss improved co-morbidities right for some ptsrisks too high to justify rewards

bull SG- needs long term research 1st step procedure low risks higher wt loss lesser complications pouch could Stretch over time long staple line could cause problems in future frequency is accelerating because of technical ease 1st stage procedure before bypass

Post-surgical Complications

Anastomosis leaks or staple line leaks Pulmonary Embolism or DVT Cholelithiasis Stomal ulceration Dumping syndrome Constipation

Anastamosis Leaks

Up to 7-10 days after surgery Most common at gastrojejunostomy enteroenterostomy Roux

limb stump staple line Can lead to peritonitis sepsis possible death Presentation

Tachycardia tachypnea Fever Ab painback pain Pelvic pressure or rebound tenderness

Anastamosis Leaks

Order Gastrograffin upper GI series Subclinical cases

Bowel rest Parenteral nutrition IV antibiotic if H pylori

Clinically suspect leak Laparoscopic evaluation and leak repair

Failure to evaluate is the most common cause of preventable major long-term disability or death in bariatric surgical patients

Pulmonary Embolism

Sudden cause of death up to one month after surgery 20-30 mortality rate High risk may have vena cava filter placement prior to surgery Prophylaxis with compression stockings and LMWH Early ambulation imperitive

Pulmonary Embolism

Presentation Profound hypoxia Hypotension Signs of sepsis

Immediate spiral chest CT Abdominal exploration if too large for machine No pathology start anticoagulation Too largehelliphellipNO SURGERY

Cholelithiasis

Up to 36 of patients within 6 months post-op Bile stasis leads to increased sludge and gallstones Prophylactic cholecystectomy prior to surgery if

evidence of existing sludge or stones Prevent post-operative disease with concurrent bariatric

surgery and cholecystectomy Prophylactic use of urosidol

Expensive and unpalatable

Stomal Ulceration

12-15 within 2-4 mos Post-surgery Etiology

Overabundant acid in pouch leads to excessive acid passing through stoma

Pouch tension and staple line breakdown NSAID use

Presentation Dyspepsia vomiting Epigastric or retrosternal pain

Stomal Ulceration

Treatment PPI carafate Antibiotics if H Pylori Avoid NSAIDS alcohol smoking

If no response to treatment Endoscopy Back to surgery for pouch revision or staple line repair

Dumping Syndrome

More than 15 patients Hypotention Tachycardia Lightheadedness syncope Flushing Abdominal cramping and diarrhea Nausea and vomiting

Dumping Syndrome

Occurs with high dose simple sugar ingestion Sugar in small intestine causes osmotic overload and fluid

shift from blood to intestine Increased intestinal volume leads to watery diarrhea Decreased blood volume leads to systemic changes Patient education

Eat slowly Avoid drinking before during and not until 30 minutes after meals

Constipation

Most common complaint Causes

Dehydration and decreased fluid intake post-operatively Increased metabolic water needs Calcium and iron supplement use following surgery

Treat with increased fluids and stool softeners

Nutritional Consequences

Iron deficiency anemia B12 deficiency Folate deficiency Calcium and Vitamin D deficiency

Not seen with purely restrictive surgeries

Iron deficiency and anemia

Common following RYGB As high as 49 of patients Multifactorial cause

Low gastric acid levels prohibit iron cleavage from food Absorption inhibited because no nutrient exposure to duodenum or

proximal jejunum Decrease in iron-rich food consumption due to intolerance

Treat with oral supplementation of ferrous sulfate or ferrous gluconate

Vitamin B12 deficiency

Up to 70 of patients Lack of hydrochloric acid and pepsin in stomach

Prevents B12 cleavage from food Affects secretion of intrinsic factor thus B12 absorption

Intolerance to meat and milk Oral supplementation usually adequate otherwise IM injections used

Folate Deficiency

40 of gastric bypass patients Complete absorption requires B12 Absorption dependent on HCl and upper 13 stomach Deficiency generally caused by decreased consumption Oral supplementation

Vitamin D and Calcium Deficiency

Vitamin D deficiency is common among obese people Calcium absorption decreased because duodenum is

bypassed Intolerance to dairy foods high in calcium Vitamin D is required for Ca++ absorption Prolonged deficiencies lead to

Bone resorption osteomalacia osteoporosis Treat with calcium citrate supplementation and 2 weekly

doses of Vitamin D

Nutritional Implications of Various Bariatric Surgeries(34)

bull RYGB Malabsorption of Vit B12 Vit B1 (thiamin) Vit D Vit K Folate Iron Calcium

bull LAGB Folic Acid deficiency

bull BPD and BPDDS Vit A D E and K deficiency Protein-Calorie Malnutrition Malabsorption of

Calcium Zinc Selenium Sodium Potassium Chloride Phosphorus Magnesium

Recommended Daily Supplements(4)

Multivitamin with iron (prenatal vitamin will have adeq amount of folic acid)

Calcium (citrate) with vitamin D (1200-1500 mg calcium with 800-1000 IU vitamin D)

Oral vitamin B12 (500-1000 mcg) Iron (65 mgday in elemental form)

Vitamin C (to increase absorption of Iron) Thiamin (10 mgday)

Diet Recommendations(3)

Reduce food volume Chew food very well Slow pace of eating No liquids with meals Encourage fruits and vegetables as diet progresses Include high protein foods (at least 60gday) may need protein

supplements

Diet Progression Gastric Bypass

Stage 1 Clear liquids and protein supplement (1 week)

Stage 2No concentrated sweets low fat puree diet ( 3 weeks)

Stage 3 Regular texture weight reduction diet

Diet Progression Lap - Band

Stage 1 Clear liquids and protein supplement ( 2 weeks)

Stage 2 No concentrated sweets low fat puree diet (2weeks)

Stage 3 Regular texture weight reduction diet

Stage 1

Only clear liquids allowed Avoid sweetened beverages Sip very slowly No straws Avoid caffeinated carbonated and alcoholic beverages STOP drinking if you feel fullness pain or discomfort

Protein supplements

Begin the day after you go home from Hospital

Minimum protein target 70gmsday

May use powder or pre-mixed liquid forms (Whey protein is preferred)

Protein pills may not be used

Vitamin and Mineral Supplements

Gastric bypass patients In addition to eating much less food gastric bypass patients will also

absorb vitamins and minerals differently after surgery They will require daily multivitamin calcium and iron

supplementation for the rest of your life

Vitamin and Mineral Supplements

Lap-Bandreg patients

Require a multivitamin with minerals daily

It may be necessary to take additional vitamins and minerals eg calcium iron folateB1 B12These will be prescribed as needed

Stage 2 dietPUREE

Puree diet

Regular scheduled meals Avoid meal skipping Plan meals in advance Eat Slowly Eat protein foods first Moisten meats Use liquid protein as supplement not as meal replacement

Measure 2 oz portions at each meal eating when full Separate liquids and solids No bread rice or pasta Avoid added sugars and high fat

foods VARIETY

Who Is a Surgical Candidate BMI gt 40 kgm2

-OR- BMI gt 35 kgm2 and major medical complications of

obesity-AND-

Failure of other approaches to long-term weight loss Age 18-55(relative)

Recommended BMI values for Bariatric Surgery in Asians

BMI ge 375

BMI ge 325 with two

associated co-

morbidities

No endocrine cause of obesity Acceptable operative risk Understands surgery and risks Absence of drug or alcohol problem No uncontrolled psychological conditions Consensus after bariatric team

evaluation SurgeonDieticianPsychologistConsultant

Dedicated to life-style change and follow-up

Obesity multidisciplinary team

Surgeon Physician Anesthetist Dietician Specialist bariatric nurse Skilled theatre staff Psychiatrist

Bariatric Surgery and Diabetes

International Diabetes Federation (2011) Journal of Diabetes (3(2011) 261-264) ldquoBariatric surgery is an appropriate treatment of people with T2D and

obesity who are not achieving recommended treatment targets with existing medical therapies especially in the presence of other major comorbiditiesrdquo

lt1 of those eligible actually have WLS for diabetes

Contraindications

Factors that may be considered contraindications include unstable CAD uncontrolled severe OSA uncontrolled psychiatric disorder mental retardation (IQ lt 60) inability to understand the surgery perceived inability to adhere to postoperative restrictions continued drug abuse malignancy with a poor 5-year survival prognosis Cirrhotic liver disease with portal hypertension

Preoperative EvaluationAttention should focus on issues unique to the obese patient

particularly cardiorespiratory status and the airwayConsideration of co morbidities ie hypertension diabetes heart

failure IHD obesity-hypoventilation syndrome metabolic syndrome etc

Results of the sleep study History of previous surgeries their anesthetic challenges need for

ICU admissionCurrent medicationsPatients scheduled for repeat bariatric surgery should be screened

preoperatively for long-term metabolic and nutritional abnormalities

Investigationshellip Recommended preoperative laboratory evaluations include

fasting blood glucose lipid profile electrolytes serum chemistries (to evaluate renal and hepatic function) complete blood count Serum ferritin vitamin B12 thyrotropin amp 25-hydroxyvitamin D

(Miller 7th edition- anesthesia for Bariatic Surgery) ABG measurements help evaluate ventilation as well as the need for perioperative oxygen administration and

postoperative ventilation Routine pulmonary function tests and liver function tests are not cost-effective in asymptomatic obese patients Coaugulation profile ( liver problem repeat surgery orlistat) ECG echocardiography Sleep study if suspected OSA

(Barash 6th edition anesthesia and obesity)

Concurrent Preoperative and Prophylactic Medications

Patients usual medications should be continued until the time of surgery with the possible exception of insulin and oral hypoglycemics

Antibiotic prophylaxis is usually indicated

Obesity itself does not increase the risk for aspiration acid aspiration prophylaxis including H2 receptor agonists or proton pump inhibitors must be considered in patients with identifiable risk for aspiration

Anxiolysis and prophylaxis against deep vein thrombosis (DVT) should be addressed at premedication

DVT consideration Morbid obesity is a major independent risk factor for sudden death from

acute postoperative pulmonary embolism Subcutaneous heparin 5000 IU administered before surgery and repeated every 8 to 12

hours until the patient is fully mobile reduces the risk of DVT LMWH can also be used

Preoperative prophylactic placement of an inferior vena cava filter should be considered in venous stasis disease BMI ge60 truncal obesity and OSA

What Are the Risks

MAJOR RISKS Death (1 of patients die within 30 days) Severe malnutrition (anemia PEM osteomalacia) Peritonitis (from leakage or ruptures at staple sites)

or other infection Obstructions caused by scar tissue in the stomach or

bowels

MINOR RISKS Dumping Syndrome (unpleasant but not harmful) Diarrhea and malodorous gas production Lactose intolerance Hair loss (short-term post-surgery) May have to eventually undergo surgical revision Pain post-surgery

History of Bariatric Surgery

Obesity surgery is not a new discipline The earliest Bariatric procedure performed was in 1954 at Minnesota The procedure

was Jejuno-ileal bypass In 1966Gastric Bypass was introduced as a surgical procedure for weight loss at the

University of Iowa In 1977Griffen reported the first Roux-en-Y Gastric Bypass In 1980surgeons with a more conservative approach developed the Vertical Banded

Gastroplasty Other procedures with longer intestinal segment bypass were also introduced such as

Biliopancreatic Diversions These complex procedures are recommended in super-obese patients ie BMIgt60

How does surgery work

RESTRICTIVE - RESTRICT AMOUNT OF FOOD INGESTED Decreases appetitehunger

Early satiety Behavior modification Gastric Banding (Lap Band)

Roux-en Y Gastric bypass (RYGB) Sleeve Gastrectomy

MALABSORPTIVE- LIMITS DIGESTION AND ABSORPTION Decreases length of intestine exposed to digested food

25 of fat is absorbed Behavior modification

Biliopancreatic Diversion Duodenal Switch (BPDDS)

ALL OPERATIONS CAN BE PERFORMED OPEN OR LAPAROSCOPICALLY

Laparoscopic vs Open

OPEN uarr post op pain Longer hospitalizations uarr wound complications

Infection Hernias Seromas

Return to work in 4-8 weeks

LAPAROSCOPIC darr post op pain Early mobility darr Wound complications 2-3 day hospital stay Return to work in 1-3 weeks

1 Nguyen NT et al Accelerated growth of bariatric surgery with the introduction of minimally invasive surgery Arch Surg 20051401198-202

Procedures that are solely restrictive by creating a small gastric pouch of volume 15 to 30 cc amp a degree of outlet obstruction leading to delayed gastric emptying The goal is to reduce oral intake by limiting gastric volume produce early satiety and leave the alimentary canal in continuity minimizing the risks of metabolic complications

1VERTICAL BANDED GASTROPLASTY

2ADJUSTABLE GASTRIC BANDING (LAGB )

3 SLEEVE GASTRECTOMY

4GASTRIC PLICATION

5 INTRA GASTRIC BALLOON (GASTRIC BALLOON)

RESTRICTIVE PROCEDURES

Malabsorption is achieved by creating a short gut syndrome andor by accomplishing distal mixing of bile and pancreatic juice with ingested nutrients thereby reducing absorption Some purely malabsorptive operations are no longer recommended due to their potential hazard to cause serious nutritional deficiencies

1 BILIOPANCREATIC DIVERSION2 THE JEJUNAL-ILEAL BYPASS3 ENDOLUMINAL SLEEVE

MALABSORPTIVE PROCEDURES

MIXED PROCEDURES

1GASTRIC BYPASS ROUX-EN-Y ( RYGBP)

2SLEEVE GASTRECTOMY WITH DUODENAL SWITCH

3IMPLANTABLE 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

The stomach is partitioned along its axis with a non-

adjustable poly-urethane band and with linear amp 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 was practiced in 1980

Vertical Banded Gastroplasty (VBG)

ADJUSTABLE GASTRIC BANDING (LAP BAND SURGERY LAGB)

Restrictive Procedure The procedure was first performed by Cadiere in 1992 but was made popular by Belachew and Legrand in 1993 An inflatable silicone BAND is placed around the top portion of the stomach to form a small stomach pouch amp sewed

This band is connected to a tube that leads to a port above the abdominal muscles placed below the skin (FILL ndash PORT)

During follow up visits we inject or remove saline solution to make the band tighter or looser

Adjustable Gastric Band

bull 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

How does the Band work

Surgery Factors Restriction of meal size Decreased appetite

Patient Factors Decreased calorie intake Increased calorie expenditure

LAP-BAND Adjustability

Unfilled Band Filled Band

Adjustments are made in the office

Complications of Gastric Lap-Band

bull Perforation of Stomachbull Slippagebull Gastric Erosion(much less after Pars flaccida technique) bull Dilated Esophagusbull Tubing access port problemsbull Mal positioningbull Abdominal Painbull Heartburnbull Vomitingbull Inability to Adjust the Bandbull Failure to Lose Weightbull Infection of Systembull Fatigue or malfunction

Advantages

No intestinal surgery No staplingcutting of stomach No nutritional risks Adjustable Reversible Safe

Foreign body Frequent follow-up visits Needs more commitment Easy to cheat

Disadvantages

Comparison of Adjustable Gastric Banding and Vertical Banded Gastroplasty

Laparoscopic adjustable gastric banding Reversible Adjustable Simpler to perform laparoscopically Sustained weight loss of gt50 EBW gt5

years following surgery Complications Gastric prolapse band

erosion rarely gastric perforation and access port complications

Vertical banded gastroplasty Irreversible Non adjustable Technically difficult by laparoscopy Weight loss of 25-50 EBW and weight gain

after 2-3 years Complications suture line disruption gastric

leak weight gain

>

>

Originally used as the first-stage operation for a proposed biliopancreatic diversion with duodenal switch in high-risk patients

The sleeve gastrectomy has caught on as a primary obesity treatment as surgeons are reporting weight loss of 55 of excess body weight past 5 years in some patients

The sleeve gastrectomy is also known as the greater curvature gastrectomy vertical or longitudinal gastrectomy or Pylorus preserving lsquogastric tube creationrsquo

Rapid and less traumatic operation Good resolution of co-morbidities and good weight loss

A further second surgical step is then easily feasible if necessary

SLEEVE GASTRECTOMY

SLEEVE GASTRECTOMY

A sleeve gastrectomy involves resection of

approximately 80 of the greater curvature

side of the stomach

Smaller tubular gastric ldquosleeverdquo created

along the lesser curve that is based on the

lesser curvature blood supply

Ideal approximate capacity of the stomach

after the procedure is about 30- 60 ml pouch

1MECHANICAL RESTRICTION by reducing the volume of the stomach and impairing stomach mobility Also called lsquoFood limitingrsquo operation

2HORMONAL MODIFICATION by removing a great part of the Ghrelin (Hunger Hormone) production tissue

(Ghrelin is a 28 amino-acid-peptide secreted by the oxyntic glands of the gastric fungus It is a potent orexigenic (appetite-stimulating) peptide mediated by the activation of its receptors in the hypothalamus or pituitary area)

The gastric fundus contains 10 to 20 times more ghrelin per one gram of tissue than the duodenum In the SG resection of the fundus removes the major portion of ghrelin release therefore appetite decreases

The sleeve gastrectomy (SG) induces weight loss by 2 mechanisms

>

Intragastric balloon involves placing a deflated balloon into the stomach and then filling it to decrease the amount of gastric space

The balloon can be left in the stomach for a maximum of 6 months and results in an average weight loss of 5ndash9 BMI over half a year

Done endoscopically

The intragastric balloon may be used prior to another bariatric surgery as a step-down procedure

INTRA GASTRIC BALLOON

>

>

The EndoBarrier gastrointestinal liner mimics the effects of gastric bypass surgery

Itrsquos designed to work by inserting a flexible

tube-like barrier into the duodenum amp 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

ENDO BARRIER LINER SYSTEM

B MAL- ABSORPTIVE PROCEDURES

Malabsorptive surgeries rearrange andor remove part of digestive system which then limits the amount of calories and nutrients that body can absorb Treatment with a large malabsorptive component results in the most weight loss but tend to have slightly higher complication rates

1JEJUNAL ILEAL BYPASS ndash no longer performed for high complication rates

2ILEAL TRANSPOSITION- New malabsoptive procedure on trial for treatment of DM type 2 and metabolic disorders

C COMBINATION PROCEDURES RESTRICTIVE + MALABSORBTIVE

1LAP GASTRIC BYPASS ndash ROUX-EN- Y ndash more malabsorption than the restrictive

2MINI- GASTRIC BYPASS- mainly restrictive

3DUODENAL SWITCH ndash the sleeve stomach is the restrictive portion ampthe intestinal bypass (duodenal switch) is the malabsorptive component

When surgery combines both restrictive and malabsorptive techniques it is know as a ldquocombinationrdquo procedure Most types of bariatric surgery carry at least a small element of both components but the following surgeries achieve a notable portion of weight loss from eachhellip

1 LAP GASTRIC BYPASS LGB

The Roux-en-Y gastric bypass(known simply as the LRYGBP) is the most commonly performed procedure

It primarily causesweight loss by restricting thefood intake however there ismore amount of mal absorption that occurs with this operation

GASTRIC BYPASS LRYGBP

bullThe stomach is stapled into2 pieces one small and one large The small piece becomes the ldquonewrdquo stomach pouch

bull The larger portion of the stomach stays in place however will lie dormant for the remainder of the patientrsquos life

GASTRIC BYPASS LGB

bull The small intestine (the jejunum) is divided using a surgical staplerApprox 50-70 cm from the DJ Junction

GASTRIC BYPASS LGB

Y- LIMB BP LIMB

bull The end of the Roux limb is then attached to the newly formed stomach pouch which carries food to the distal intestine

bull The Roux loop is completed by forming a jejunostomy

bull The Y limb or BPD limb carries digestive juices from the pancreas gall bladder liver and duodenum to the intestines

bull The food and the digestive juices mix where the Roux limb and Y limb meet much below say 100-150 cm from DJ

Roux limb or alimentary limb

100-150 cm

How Does the Roux-en-Y Work

Surgery factors restriction of meal size ldquodumping syndromerdquo some malabsorption decreased appetite

Patient factors calorie intake calorie expenditure

bull Most commonly performedbull Most reliable operation for long term weight lossbull Long term weight loss averages 60 to 75 percent of EBWbull Malnutrition is unusualbull Substantial improvement amp resolution in many co-morbid

obesity conditions

ADVANTAGES OF RYGBP

1 Not reversible

2 Mortality 05- 1

3 Perioperative complications 5-10

4 Stricture of gastrojejunostomy-10 (long term)

5 Long term risk of protein amp vitamin deficiency and marginal ulceration of GJA

6Long term risk of intestinal obstruction ndash 2

LAPAROSCOPIC GASTRIC BYPASSCOMPLICATIONS

Biliopancreatic Diversion (BPD)

Primarily malabsorptive but restrictive component also

First Terminal ileum is measured to a length of 50 cms marked with suture

The alimentary tract beyond the proximal part of stomach is rearranged to

include only distal 200 cm of ileum including common channel

Common channel-Distal 50 cm of terminal ileum for absorption of fat and

protein

The proximal end of ileum anastomosed to proximal end of stomach after

performing distal hemigastrectomy

Biliopancreatic Diversion with Duodenal Switch

Modification to lessen high incidence of vit b12 deficiency anastomotic stricture at gastrojejunal anastomosis

This procedure involves a sleeve gastrectomy that is then diverted at the duodenum into the ileum at a point measured proximally from the ileocecal valve (usually 250 cm)

The distal duodenum and jejunum the biliopancreatic limb are then anastomosed to the ileum at a point measured proximally from the ileocecal valve (usually 100 cm)

Common channel is 100cm Entire alimentary tract is 250 cm This is the most aggressive bypass procedure commonly offered today Major difference-Sleeve gastrectomy instead of distal hemigastrectomy

bull Most women regained normal menstrual function and most had documented

spontaneous ovulation

bull Significant improvement in hirsutism androgen profiles and about a 50 reduction in

HOMA-IR

bull Follow up for more than 2 years showed that all women resumed normal menstrual

cycles HbA1C decreased from 82 to 51 in lt 3 months

bull 78 saw improvement in metabolic syndrome amp 48 showed improvement in PCOS

2 ROLE OF BARIATRIC SURGERY IN PCOS PATIENTS

bull Decrease menstrual irregularities bull PCOS women have less hyper androgenism

bull Sex hormone binding globulin increases bull LH and FSH levels have been reported to increase

bull Ovulatory function measured by luteal LH and Progesterone secretion improved bull Leptin levels decrease reflecting improved reproductive metabolic status

bull Subclinical hypothyroidism significantly reduced

THE SAFE TIMING OF PREGNANCYoptimal or minimal time gt12 months after bariatric surgery before becoming pregnant in order to allow the rapid weight loss and metabolic changes to subside

4 BARIATRIC SURGERY IN REPRODUCTIVE WOMEN

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)

The foregut hypothesis theory ndash 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

Effect of Bariatric Surgery on Diabetes Mellitus

Combined Gastric Restriction amp Malabsorption

Operative Risks (vs cholecystectomy)

Perioperative Mortality 1-2 vs 02-08 Early Complications 10 vs 29Late Complications 20 vs 1-2

LimitationsWidening of (unbanded) gastrojejunostomyExpansion of gastric pouch 25 with nearly 100 weight regainAdaptation of limb that receives the food

SUMMARY OF ALL TYPES OF SURGERY

bull LRYGBP ndash worlds best procedure 60-70 WL dumping syndrome malnutrition

bull LAGB- low complications varying range of wt loss frequent post-op visits ( 10)

bull DSBPD- more wt loss high complications good for high BMI gt 50 malabsorption +

bull VBG(vertical band gastroplasty) ndash longest available results good wt loss improved co-morbidities right for some ptsrisks too high to justify rewards

bull SG- needs long term research 1st step procedure low risks higher wt loss lesser complications pouch could Stretch over time long staple line could cause problems in future frequency is accelerating because of technical ease 1st stage procedure before bypass

Post-surgical Complications

Anastomosis leaks or staple line leaks Pulmonary Embolism or DVT Cholelithiasis Stomal ulceration Dumping syndrome Constipation

Anastamosis Leaks

Up to 7-10 days after surgery Most common at gastrojejunostomy enteroenterostomy Roux

limb stump staple line Can lead to peritonitis sepsis possible death Presentation

Tachycardia tachypnea Fever Ab painback pain Pelvic pressure or rebound tenderness

Anastamosis Leaks

Order Gastrograffin upper GI series Subclinical cases

Bowel rest Parenteral nutrition IV antibiotic if H pylori

Clinically suspect leak Laparoscopic evaluation and leak repair

Failure to evaluate is the most common cause of preventable major long-term disability or death in bariatric surgical patients

Pulmonary Embolism

Sudden cause of death up to one month after surgery 20-30 mortality rate High risk may have vena cava filter placement prior to surgery Prophylaxis with compression stockings and LMWH Early ambulation imperitive

Pulmonary Embolism

Presentation Profound hypoxia Hypotension Signs of sepsis

Immediate spiral chest CT Abdominal exploration if too large for machine No pathology start anticoagulation Too largehelliphellipNO SURGERY

Cholelithiasis

Up to 36 of patients within 6 months post-op Bile stasis leads to increased sludge and gallstones Prophylactic cholecystectomy prior to surgery if

evidence of existing sludge or stones Prevent post-operative disease with concurrent bariatric

surgery and cholecystectomy Prophylactic use of urosidol

Expensive and unpalatable

Stomal Ulceration

12-15 within 2-4 mos Post-surgery Etiology

Overabundant acid in pouch leads to excessive acid passing through stoma

Pouch tension and staple line breakdown NSAID use

Presentation Dyspepsia vomiting Epigastric or retrosternal pain

Stomal Ulceration

Treatment PPI carafate Antibiotics if H Pylori Avoid NSAIDS alcohol smoking

If no response to treatment Endoscopy Back to surgery for pouch revision or staple line repair

Dumping Syndrome

More than 15 patients Hypotention Tachycardia Lightheadedness syncope Flushing Abdominal cramping and diarrhea Nausea and vomiting

Dumping Syndrome

Occurs with high dose simple sugar ingestion Sugar in small intestine causes osmotic overload and fluid

shift from blood to intestine Increased intestinal volume leads to watery diarrhea Decreased blood volume leads to systemic changes Patient education

Eat slowly Avoid drinking before during and not until 30 minutes after meals

Constipation

Most common complaint Causes

Dehydration and decreased fluid intake post-operatively Increased metabolic water needs Calcium and iron supplement use following surgery

Treat with increased fluids and stool softeners

Nutritional Consequences

Iron deficiency anemia B12 deficiency Folate deficiency Calcium and Vitamin D deficiency

Not seen with purely restrictive surgeries

Iron deficiency and anemia

Common following RYGB As high as 49 of patients Multifactorial cause

Low gastric acid levels prohibit iron cleavage from food Absorption inhibited because no nutrient exposure to duodenum or

proximal jejunum Decrease in iron-rich food consumption due to intolerance

Treat with oral supplementation of ferrous sulfate or ferrous gluconate

Vitamin B12 deficiency

Up to 70 of patients Lack of hydrochloric acid and pepsin in stomach

Prevents B12 cleavage from food Affects secretion of intrinsic factor thus B12 absorption

Intolerance to meat and milk Oral supplementation usually adequate otherwise IM injections used

Folate Deficiency

40 of gastric bypass patients Complete absorption requires B12 Absorption dependent on HCl and upper 13 stomach Deficiency generally caused by decreased consumption Oral supplementation

Vitamin D and Calcium Deficiency

Vitamin D deficiency is common among obese people Calcium absorption decreased because duodenum is

bypassed Intolerance to dairy foods high in calcium Vitamin D is required for Ca++ absorption Prolonged deficiencies lead to

Bone resorption osteomalacia osteoporosis Treat with calcium citrate supplementation and 2 weekly

doses of Vitamin D

Nutritional Implications of Various Bariatric Surgeries(34)

bull RYGB Malabsorption of Vit B12 Vit B1 (thiamin) Vit D Vit K Folate Iron Calcium

bull LAGB Folic Acid deficiency

bull BPD and BPDDS Vit A D E and K deficiency Protein-Calorie Malnutrition Malabsorption of

Calcium Zinc Selenium Sodium Potassium Chloride Phosphorus Magnesium

Recommended Daily Supplements(4)

Multivitamin with iron (prenatal vitamin will have adeq amount of folic acid)

Calcium (citrate) with vitamin D (1200-1500 mg calcium with 800-1000 IU vitamin D)

Oral vitamin B12 (500-1000 mcg) Iron (65 mgday in elemental form)

Vitamin C (to increase absorption of Iron) Thiamin (10 mgday)

Diet Recommendations(3)

Reduce food volume Chew food very well Slow pace of eating No liquids with meals Encourage fruits and vegetables as diet progresses Include high protein foods (at least 60gday) may need protein

supplements

Diet Progression Gastric Bypass

Stage 1 Clear liquids and protein supplement (1 week)

Stage 2No concentrated sweets low fat puree diet ( 3 weeks)

Stage 3 Regular texture weight reduction diet

Diet Progression Lap - Band

Stage 1 Clear liquids and protein supplement ( 2 weeks)

Stage 2 No concentrated sweets low fat puree diet (2weeks)

Stage 3 Regular texture weight reduction diet

Stage 1

Only clear liquids allowed Avoid sweetened beverages Sip very slowly No straws Avoid caffeinated carbonated and alcoholic beverages STOP drinking if you feel fullness pain or discomfort

Protein supplements

Begin the day after you go home from Hospital

Minimum protein target 70gmsday

May use powder or pre-mixed liquid forms (Whey protein is preferred)

Protein pills may not be used

Vitamin and Mineral Supplements

Gastric bypass patients In addition to eating much less food gastric bypass patients will also

absorb vitamins and minerals differently after surgery They will require daily multivitamin calcium and iron

supplementation for the rest of your life

Vitamin and Mineral Supplements

Lap-Bandreg patients

Require a multivitamin with minerals daily

It may be necessary to take additional vitamins and minerals eg calcium iron folateB1 B12These will be prescribed as needed

Stage 2 dietPUREE

Puree diet

Regular scheduled meals Avoid meal skipping Plan meals in advance Eat Slowly Eat protein foods first Moisten meats Use liquid protein as supplement not as meal replacement

Measure 2 oz portions at each meal eating when full Separate liquids and solids No bread rice or pasta Avoid added sugars and high fat

foods VARIETY

Recommended BMI values for Bariatric Surgery in Asians

BMI ge 375

BMI ge 325 with two

associated co-

morbidities

No endocrine cause of obesity Acceptable operative risk Understands surgery and risks Absence of drug or alcohol problem No uncontrolled psychological conditions Consensus after bariatric team

evaluation SurgeonDieticianPsychologistConsultant

Dedicated to life-style change and follow-up

Obesity multidisciplinary team

Surgeon Physician Anesthetist Dietician Specialist bariatric nurse Skilled theatre staff Psychiatrist

Bariatric Surgery and Diabetes

International Diabetes Federation (2011) Journal of Diabetes (3(2011) 261-264) ldquoBariatric surgery is an appropriate treatment of people with T2D and

obesity who are not achieving recommended treatment targets with existing medical therapies especially in the presence of other major comorbiditiesrdquo

lt1 of those eligible actually have WLS for diabetes

Contraindications

Factors that may be considered contraindications include unstable CAD uncontrolled severe OSA uncontrolled psychiatric disorder mental retardation (IQ lt 60) inability to understand the surgery perceived inability to adhere to postoperative restrictions continued drug abuse malignancy with a poor 5-year survival prognosis Cirrhotic liver disease with portal hypertension

Preoperative EvaluationAttention should focus on issues unique to the obese patient

particularly cardiorespiratory status and the airwayConsideration of co morbidities ie hypertension diabetes heart

failure IHD obesity-hypoventilation syndrome metabolic syndrome etc

Results of the sleep study History of previous surgeries their anesthetic challenges need for

ICU admissionCurrent medicationsPatients scheduled for repeat bariatric surgery should be screened

preoperatively for long-term metabolic and nutritional abnormalities

Investigationshellip Recommended preoperative laboratory evaluations include

fasting blood glucose lipid profile electrolytes serum chemistries (to evaluate renal and hepatic function) complete blood count Serum ferritin vitamin B12 thyrotropin amp 25-hydroxyvitamin D

(Miller 7th edition- anesthesia for Bariatic Surgery) ABG measurements help evaluate ventilation as well as the need for perioperative oxygen administration and

postoperative ventilation Routine pulmonary function tests and liver function tests are not cost-effective in asymptomatic obese patients Coaugulation profile ( liver problem repeat surgery orlistat) ECG echocardiography Sleep study if suspected OSA

(Barash 6th edition anesthesia and obesity)

Concurrent Preoperative and Prophylactic Medications

Patients usual medications should be continued until the time of surgery with the possible exception of insulin and oral hypoglycemics

Antibiotic prophylaxis is usually indicated

Obesity itself does not increase the risk for aspiration acid aspiration prophylaxis including H2 receptor agonists or proton pump inhibitors must be considered in patients with identifiable risk for aspiration

Anxiolysis and prophylaxis against deep vein thrombosis (DVT) should be addressed at premedication

DVT consideration Morbid obesity is a major independent risk factor for sudden death from

acute postoperative pulmonary embolism Subcutaneous heparin 5000 IU administered before surgery and repeated every 8 to 12

hours until the patient is fully mobile reduces the risk of DVT LMWH can also be used

Preoperative prophylactic placement of an inferior vena cava filter should be considered in venous stasis disease BMI ge60 truncal obesity and OSA

What Are the Risks

MAJOR RISKS Death (1 of patients die within 30 days) Severe malnutrition (anemia PEM osteomalacia) Peritonitis (from leakage or ruptures at staple sites)

or other infection Obstructions caused by scar tissue in the stomach or

bowels

MINOR RISKS Dumping Syndrome (unpleasant but not harmful) Diarrhea and malodorous gas production Lactose intolerance Hair loss (short-term post-surgery) May have to eventually undergo surgical revision Pain post-surgery

History of Bariatric Surgery

Obesity surgery is not a new discipline The earliest Bariatric procedure performed was in 1954 at Minnesota The procedure

was Jejuno-ileal bypass In 1966Gastric Bypass was introduced as a surgical procedure for weight loss at the

University of Iowa In 1977Griffen reported the first Roux-en-Y Gastric Bypass In 1980surgeons with a more conservative approach developed the Vertical Banded

Gastroplasty Other procedures with longer intestinal segment bypass were also introduced such as

Biliopancreatic Diversions These complex procedures are recommended in super-obese patients ie BMIgt60

How does surgery work

RESTRICTIVE - RESTRICT AMOUNT OF FOOD INGESTED Decreases appetitehunger

Early satiety Behavior modification Gastric Banding (Lap Band)

Roux-en Y Gastric bypass (RYGB) Sleeve Gastrectomy

MALABSORPTIVE- LIMITS DIGESTION AND ABSORPTION Decreases length of intestine exposed to digested food

25 of fat is absorbed Behavior modification

Biliopancreatic Diversion Duodenal Switch (BPDDS)

ALL OPERATIONS CAN BE PERFORMED OPEN OR LAPAROSCOPICALLY

Laparoscopic vs Open

OPEN uarr post op pain Longer hospitalizations uarr wound complications

Infection Hernias Seromas

Return to work in 4-8 weeks

LAPAROSCOPIC darr post op pain Early mobility darr Wound complications 2-3 day hospital stay Return to work in 1-3 weeks

1 Nguyen NT et al Accelerated growth of bariatric surgery with the introduction of minimally invasive surgery Arch Surg 20051401198-202

Procedures that are solely restrictive by creating a small gastric pouch of volume 15 to 30 cc amp a degree of outlet obstruction leading to delayed gastric emptying The goal is to reduce oral intake by limiting gastric volume produce early satiety and leave the alimentary canal in continuity minimizing the risks of metabolic complications

1VERTICAL BANDED GASTROPLASTY

2ADJUSTABLE GASTRIC BANDING (LAGB )

3 SLEEVE GASTRECTOMY

4GASTRIC PLICATION

5 INTRA GASTRIC BALLOON (GASTRIC BALLOON)

RESTRICTIVE PROCEDURES

Malabsorption is achieved by creating a short gut syndrome andor by accomplishing distal mixing of bile and pancreatic juice with ingested nutrients thereby reducing absorption Some purely malabsorptive operations are no longer recommended due to their potential hazard to cause serious nutritional deficiencies

1 BILIOPANCREATIC DIVERSION2 THE JEJUNAL-ILEAL BYPASS3 ENDOLUMINAL SLEEVE

MALABSORPTIVE PROCEDURES

MIXED PROCEDURES

1GASTRIC BYPASS ROUX-EN-Y ( RYGBP)

2SLEEVE GASTRECTOMY WITH DUODENAL SWITCH

3IMPLANTABLE 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

The stomach is partitioned along its axis with a non-

adjustable poly-urethane band and with linear amp 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 was practiced in 1980

Vertical Banded Gastroplasty (VBG)

ADJUSTABLE GASTRIC BANDING (LAP BAND SURGERY LAGB)

Restrictive Procedure The procedure was first performed by Cadiere in 1992 but was made popular by Belachew and Legrand in 1993 An inflatable silicone BAND is placed around the top portion of the stomach to form a small stomach pouch amp sewed

This band is connected to a tube that leads to a port above the abdominal muscles placed below the skin (FILL ndash PORT)

During follow up visits we inject or remove saline solution to make the band tighter or looser

Adjustable Gastric Band

bull 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

How does the Band work

Surgery Factors Restriction of meal size Decreased appetite

Patient Factors Decreased calorie intake Increased calorie expenditure

LAP-BAND Adjustability

Unfilled Band Filled Band

Adjustments are made in the office

Complications of Gastric Lap-Band

bull Perforation of Stomachbull Slippagebull Gastric Erosion(much less after Pars flaccida technique) bull Dilated Esophagusbull Tubing access port problemsbull Mal positioningbull Abdominal Painbull Heartburnbull Vomitingbull Inability to Adjust the Bandbull Failure to Lose Weightbull Infection of Systembull Fatigue or malfunction

Advantages

No intestinal surgery No staplingcutting of stomach No nutritional risks Adjustable Reversible Safe

Foreign body Frequent follow-up visits Needs more commitment Easy to cheat

Disadvantages

Comparison of Adjustable Gastric Banding and Vertical Banded Gastroplasty

Laparoscopic adjustable gastric banding Reversible Adjustable Simpler to perform laparoscopically Sustained weight loss of gt50 EBW gt5

years following surgery Complications Gastric prolapse band

erosion rarely gastric perforation and access port complications

Vertical banded gastroplasty Irreversible Non adjustable Technically difficult by laparoscopy Weight loss of 25-50 EBW and weight gain

after 2-3 years Complications suture line disruption gastric

leak weight gain

>

>

Originally used as the first-stage operation for a proposed biliopancreatic diversion with duodenal switch in high-risk patients

The sleeve gastrectomy has caught on as a primary obesity treatment as surgeons are reporting weight loss of 55 of excess body weight past 5 years in some patients

The sleeve gastrectomy is also known as the greater curvature gastrectomy vertical or longitudinal gastrectomy or Pylorus preserving lsquogastric tube creationrsquo

Rapid and less traumatic operation Good resolution of co-morbidities and good weight loss

A further second surgical step is then easily feasible if necessary

SLEEVE GASTRECTOMY

SLEEVE GASTRECTOMY

A sleeve gastrectomy involves resection of

approximately 80 of the greater curvature

side of the stomach

Smaller tubular gastric ldquosleeverdquo created

along the lesser curve that is based on the

lesser curvature blood supply

Ideal approximate capacity of the stomach

after the procedure is about 30- 60 ml pouch

1MECHANICAL RESTRICTION by reducing the volume of the stomach and impairing stomach mobility Also called lsquoFood limitingrsquo operation

2HORMONAL MODIFICATION by removing a great part of the Ghrelin (Hunger Hormone) production tissue

(Ghrelin is a 28 amino-acid-peptide secreted by the oxyntic glands of the gastric fungus It is a potent orexigenic (appetite-stimulating) peptide mediated by the activation of its receptors in the hypothalamus or pituitary area)

The gastric fundus contains 10 to 20 times more ghrelin per one gram of tissue than the duodenum In the SG resection of the fundus removes the major portion of ghrelin release therefore appetite decreases

The sleeve gastrectomy (SG) induces weight loss by 2 mechanisms

>

Intragastric balloon involves placing a deflated balloon into the stomach and then filling it to decrease the amount of gastric space

The balloon can be left in the stomach for a maximum of 6 months and results in an average weight loss of 5ndash9 BMI over half a year

Done endoscopically

The intragastric balloon may be used prior to another bariatric surgery as a step-down procedure

INTRA GASTRIC BALLOON

>

>

The EndoBarrier gastrointestinal liner mimics the effects of gastric bypass surgery

Itrsquos designed to work by inserting a flexible

tube-like barrier into the duodenum amp 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

ENDO BARRIER LINER SYSTEM

B MAL- ABSORPTIVE PROCEDURES

Malabsorptive surgeries rearrange andor remove part of digestive system which then limits the amount of calories and nutrients that body can absorb Treatment with a large malabsorptive component results in the most weight loss but tend to have slightly higher complication rates

1JEJUNAL ILEAL BYPASS ndash no longer performed for high complication rates

2ILEAL TRANSPOSITION- New malabsoptive procedure on trial for treatment of DM type 2 and metabolic disorders

C COMBINATION PROCEDURES RESTRICTIVE + MALABSORBTIVE

1LAP GASTRIC BYPASS ndash ROUX-EN- Y ndash more malabsorption than the restrictive

2MINI- GASTRIC BYPASS- mainly restrictive

3DUODENAL SWITCH ndash the sleeve stomach is the restrictive portion ampthe intestinal bypass (duodenal switch) is the malabsorptive component

When surgery combines both restrictive and malabsorptive techniques it is know as a ldquocombinationrdquo procedure Most types of bariatric surgery carry at least a small element of both components but the following surgeries achieve a notable portion of weight loss from eachhellip

1 LAP GASTRIC BYPASS LGB

The Roux-en-Y gastric bypass(known simply as the LRYGBP) is the most commonly performed procedure

It primarily causesweight loss by restricting thefood intake however there ismore amount of mal absorption that occurs with this operation

GASTRIC BYPASS LRYGBP

bullThe stomach is stapled into2 pieces one small and one large The small piece becomes the ldquonewrdquo stomach pouch

bull The larger portion of the stomach stays in place however will lie dormant for the remainder of the patientrsquos life

GASTRIC BYPASS LGB

bull The small intestine (the jejunum) is divided using a surgical staplerApprox 50-70 cm from the DJ Junction

GASTRIC BYPASS LGB

Y- LIMB BP LIMB

bull The end of the Roux limb is then attached to the newly formed stomach pouch which carries food to the distal intestine

bull The Roux loop is completed by forming a jejunostomy

bull The Y limb or BPD limb carries digestive juices from the pancreas gall bladder liver and duodenum to the intestines

bull The food and the digestive juices mix where the Roux limb and Y limb meet much below say 100-150 cm from DJ

Roux limb or alimentary limb

100-150 cm

How Does the Roux-en-Y Work

Surgery factors restriction of meal size ldquodumping syndromerdquo some malabsorption decreased appetite

Patient factors calorie intake calorie expenditure

bull Most commonly performedbull Most reliable operation for long term weight lossbull Long term weight loss averages 60 to 75 percent of EBWbull Malnutrition is unusualbull Substantial improvement amp resolution in many co-morbid

obesity conditions

ADVANTAGES OF RYGBP

1 Not reversible

2 Mortality 05- 1

3 Perioperative complications 5-10

4 Stricture of gastrojejunostomy-10 (long term)

5 Long term risk of protein amp vitamin deficiency and marginal ulceration of GJA

6Long term risk of intestinal obstruction ndash 2

LAPAROSCOPIC GASTRIC BYPASSCOMPLICATIONS

Biliopancreatic Diversion (BPD)

Primarily malabsorptive but restrictive component also

First Terminal ileum is measured to a length of 50 cms marked with suture

The alimentary tract beyond the proximal part of stomach is rearranged to

include only distal 200 cm of ileum including common channel

Common channel-Distal 50 cm of terminal ileum for absorption of fat and

protein

The proximal end of ileum anastomosed to proximal end of stomach after

performing distal hemigastrectomy

Biliopancreatic Diversion with Duodenal Switch

Modification to lessen high incidence of vit b12 deficiency anastomotic stricture at gastrojejunal anastomosis

This procedure involves a sleeve gastrectomy that is then diverted at the duodenum into the ileum at a point measured proximally from the ileocecal valve (usually 250 cm)

The distal duodenum and jejunum the biliopancreatic limb are then anastomosed to the ileum at a point measured proximally from the ileocecal valve (usually 100 cm)

Common channel is 100cm Entire alimentary tract is 250 cm This is the most aggressive bypass procedure commonly offered today Major difference-Sleeve gastrectomy instead of distal hemigastrectomy

bull Most women regained normal menstrual function and most had documented

spontaneous ovulation

bull Significant improvement in hirsutism androgen profiles and about a 50 reduction in

HOMA-IR

bull Follow up for more than 2 years showed that all women resumed normal menstrual

cycles HbA1C decreased from 82 to 51 in lt 3 months

bull 78 saw improvement in metabolic syndrome amp 48 showed improvement in PCOS

2 ROLE OF BARIATRIC SURGERY IN PCOS PATIENTS

bull Decrease menstrual irregularities bull PCOS women have less hyper androgenism

bull Sex hormone binding globulin increases bull LH and FSH levels have been reported to increase

bull Ovulatory function measured by luteal LH and Progesterone secretion improved bull Leptin levels decrease reflecting improved reproductive metabolic status

bull Subclinical hypothyroidism significantly reduced

THE SAFE TIMING OF PREGNANCYoptimal or minimal time gt12 months after bariatric surgery before becoming pregnant in order to allow the rapid weight loss and metabolic changes to subside

4 BARIATRIC SURGERY IN REPRODUCTIVE WOMEN

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)

The foregut hypothesis theory ndash 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

Effect of Bariatric Surgery on Diabetes Mellitus

Combined Gastric Restriction amp Malabsorption

Operative Risks (vs cholecystectomy)

Perioperative Mortality 1-2 vs 02-08 Early Complications 10 vs 29Late Complications 20 vs 1-2

LimitationsWidening of (unbanded) gastrojejunostomyExpansion of gastric pouch 25 with nearly 100 weight regainAdaptation of limb that receives the food

SUMMARY OF ALL TYPES OF SURGERY

bull LRYGBP ndash worlds best procedure 60-70 WL dumping syndrome malnutrition

bull LAGB- low complications varying range of wt loss frequent post-op visits ( 10)

bull DSBPD- more wt loss high complications good for high BMI gt 50 malabsorption +

bull VBG(vertical band gastroplasty) ndash longest available results good wt loss improved co-morbidities right for some ptsrisks too high to justify rewards

bull SG- needs long term research 1st step procedure low risks higher wt loss lesser complications pouch could Stretch over time long staple line could cause problems in future frequency is accelerating because of technical ease 1st stage procedure before bypass

Post-surgical Complications

Anastomosis leaks or staple line leaks Pulmonary Embolism or DVT Cholelithiasis Stomal ulceration Dumping syndrome Constipation

Anastamosis Leaks

Up to 7-10 days after surgery Most common at gastrojejunostomy enteroenterostomy Roux

limb stump staple line Can lead to peritonitis sepsis possible death Presentation

Tachycardia tachypnea Fever Ab painback pain Pelvic pressure or rebound tenderness

Anastamosis Leaks

Order Gastrograffin upper GI series Subclinical cases

Bowel rest Parenteral nutrition IV antibiotic if H pylori

Clinically suspect leak Laparoscopic evaluation and leak repair

Failure to evaluate is the most common cause of preventable major long-term disability or death in bariatric surgical patients

Pulmonary Embolism

Sudden cause of death up to one month after surgery 20-30 mortality rate High risk may have vena cava filter placement prior to surgery Prophylaxis with compression stockings and LMWH Early ambulation imperitive

Pulmonary Embolism

Presentation Profound hypoxia Hypotension Signs of sepsis

Immediate spiral chest CT Abdominal exploration if too large for machine No pathology start anticoagulation Too largehelliphellipNO SURGERY

Cholelithiasis

Up to 36 of patients within 6 months post-op Bile stasis leads to increased sludge and gallstones Prophylactic cholecystectomy prior to surgery if

evidence of existing sludge or stones Prevent post-operative disease with concurrent bariatric

surgery and cholecystectomy Prophylactic use of urosidol

Expensive and unpalatable

Stomal Ulceration

12-15 within 2-4 mos Post-surgery Etiology

Overabundant acid in pouch leads to excessive acid passing through stoma

Pouch tension and staple line breakdown NSAID use

Presentation Dyspepsia vomiting Epigastric or retrosternal pain

Stomal Ulceration

Treatment PPI carafate Antibiotics if H Pylori Avoid NSAIDS alcohol smoking

If no response to treatment Endoscopy Back to surgery for pouch revision or staple line repair

Dumping Syndrome

More than 15 patients Hypotention Tachycardia Lightheadedness syncope Flushing Abdominal cramping and diarrhea Nausea and vomiting

Dumping Syndrome

Occurs with high dose simple sugar ingestion Sugar in small intestine causes osmotic overload and fluid

shift from blood to intestine Increased intestinal volume leads to watery diarrhea Decreased blood volume leads to systemic changes Patient education

Eat slowly Avoid drinking before during and not until 30 minutes after meals

Constipation

Most common complaint Causes

Dehydration and decreased fluid intake post-operatively Increased metabolic water needs Calcium and iron supplement use following surgery

Treat with increased fluids and stool softeners

Nutritional Consequences

Iron deficiency anemia B12 deficiency Folate deficiency Calcium and Vitamin D deficiency

Not seen with purely restrictive surgeries

Iron deficiency and anemia

Common following RYGB As high as 49 of patients Multifactorial cause

Low gastric acid levels prohibit iron cleavage from food Absorption inhibited because no nutrient exposure to duodenum or

proximal jejunum Decrease in iron-rich food consumption due to intolerance

Treat with oral supplementation of ferrous sulfate or ferrous gluconate

Vitamin B12 deficiency

Up to 70 of patients Lack of hydrochloric acid and pepsin in stomach

Prevents B12 cleavage from food Affects secretion of intrinsic factor thus B12 absorption

Intolerance to meat and milk Oral supplementation usually adequate otherwise IM injections used

Folate Deficiency

40 of gastric bypass patients Complete absorption requires B12 Absorption dependent on HCl and upper 13 stomach Deficiency generally caused by decreased consumption Oral supplementation

Vitamin D and Calcium Deficiency

Vitamin D deficiency is common among obese people Calcium absorption decreased because duodenum is

bypassed Intolerance to dairy foods high in calcium Vitamin D is required for Ca++ absorption Prolonged deficiencies lead to

Bone resorption osteomalacia osteoporosis Treat with calcium citrate supplementation and 2 weekly

doses of Vitamin D

Nutritional Implications of Various Bariatric Surgeries(34)

bull RYGB Malabsorption of Vit B12 Vit B1 (thiamin) Vit D Vit K Folate Iron Calcium

bull LAGB Folic Acid deficiency

bull BPD and BPDDS Vit A D E and K deficiency Protein-Calorie Malnutrition Malabsorption of

Calcium Zinc Selenium Sodium Potassium Chloride Phosphorus Magnesium

Recommended Daily Supplements(4)

Multivitamin with iron (prenatal vitamin will have adeq amount of folic acid)

Calcium (citrate) with vitamin D (1200-1500 mg calcium with 800-1000 IU vitamin D)

Oral vitamin B12 (500-1000 mcg) Iron (65 mgday in elemental form)

Vitamin C (to increase absorption of Iron) Thiamin (10 mgday)

Diet Recommendations(3)

Reduce food volume Chew food very well Slow pace of eating No liquids with meals Encourage fruits and vegetables as diet progresses Include high protein foods (at least 60gday) may need protein

supplements

Diet Progression Gastric Bypass

Stage 1 Clear liquids and protein supplement (1 week)

Stage 2No concentrated sweets low fat puree diet ( 3 weeks)

Stage 3 Regular texture weight reduction diet

Diet Progression Lap - Band

Stage 1 Clear liquids and protein supplement ( 2 weeks)

Stage 2 No concentrated sweets low fat puree diet (2weeks)

Stage 3 Regular texture weight reduction diet

Stage 1

Only clear liquids allowed Avoid sweetened beverages Sip very slowly No straws Avoid caffeinated carbonated and alcoholic beverages STOP drinking if you feel fullness pain or discomfort

Protein supplements

Begin the day after you go home from Hospital

Minimum protein target 70gmsday

May use powder or pre-mixed liquid forms (Whey protein is preferred)

Protein pills may not be used

Vitamin and Mineral Supplements

Gastric bypass patients In addition to eating much less food gastric bypass patients will also

absorb vitamins and minerals differently after surgery They will require daily multivitamin calcium and iron

supplementation for the rest of your life

Vitamin and Mineral Supplements

Lap-Bandreg patients

Require a multivitamin with minerals daily

It may be necessary to take additional vitamins and minerals eg calcium iron folateB1 B12These will be prescribed as needed

Stage 2 dietPUREE

Puree diet

Regular scheduled meals Avoid meal skipping Plan meals in advance Eat Slowly Eat protein foods first Moisten meats Use liquid protein as supplement not as meal replacement

Measure 2 oz portions at each meal eating when full Separate liquids and solids No bread rice or pasta Avoid added sugars and high fat

foods VARIETY

No endocrine cause of obesity Acceptable operative risk Understands surgery and risks Absence of drug or alcohol problem No uncontrolled psychological conditions Consensus after bariatric team

evaluation SurgeonDieticianPsychologistConsultant

Dedicated to life-style change and follow-up

Obesity multidisciplinary team

Surgeon Physician Anesthetist Dietician Specialist bariatric nurse Skilled theatre staff Psychiatrist

Bariatric Surgery and Diabetes

International Diabetes Federation (2011) Journal of Diabetes (3(2011) 261-264) ldquoBariatric surgery is an appropriate treatment of people with T2D and

obesity who are not achieving recommended treatment targets with existing medical therapies especially in the presence of other major comorbiditiesrdquo

lt1 of those eligible actually have WLS for diabetes

Contraindications

Factors that may be considered contraindications include unstable CAD uncontrolled severe OSA uncontrolled psychiatric disorder mental retardation (IQ lt 60) inability to understand the surgery perceived inability to adhere to postoperative restrictions continued drug abuse malignancy with a poor 5-year survival prognosis Cirrhotic liver disease with portal hypertension

Preoperative EvaluationAttention should focus on issues unique to the obese patient

particularly cardiorespiratory status and the airwayConsideration of co morbidities ie hypertension diabetes heart

failure IHD obesity-hypoventilation syndrome metabolic syndrome etc

Results of the sleep study History of previous surgeries their anesthetic challenges need for

ICU admissionCurrent medicationsPatients scheduled for repeat bariatric surgery should be screened

preoperatively for long-term metabolic and nutritional abnormalities

Investigationshellip Recommended preoperative laboratory evaluations include

fasting blood glucose lipid profile electrolytes serum chemistries (to evaluate renal and hepatic function) complete blood count Serum ferritin vitamin B12 thyrotropin amp 25-hydroxyvitamin D

(Miller 7th edition- anesthesia for Bariatic Surgery) ABG measurements help evaluate ventilation as well as the need for perioperative oxygen administration and

postoperative ventilation Routine pulmonary function tests and liver function tests are not cost-effective in asymptomatic obese patients Coaugulation profile ( liver problem repeat surgery orlistat) ECG echocardiography Sleep study if suspected OSA

(Barash 6th edition anesthesia and obesity)

Concurrent Preoperative and Prophylactic Medications

Patients usual medications should be continued until the time of surgery with the possible exception of insulin and oral hypoglycemics

Antibiotic prophylaxis is usually indicated

Obesity itself does not increase the risk for aspiration acid aspiration prophylaxis including H2 receptor agonists or proton pump inhibitors must be considered in patients with identifiable risk for aspiration

Anxiolysis and prophylaxis against deep vein thrombosis (DVT) should be addressed at premedication

DVT consideration Morbid obesity is a major independent risk factor for sudden death from

acute postoperative pulmonary embolism Subcutaneous heparin 5000 IU administered before surgery and repeated every 8 to 12

hours until the patient is fully mobile reduces the risk of DVT LMWH can also be used

Preoperative prophylactic placement of an inferior vena cava filter should be considered in venous stasis disease BMI ge60 truncal obesity and OSA

What Are the Risks

MAJOR RISKS Death (1 of patients die within 30 days) Severe malnutrition (anemia PEM osteomalacia) Peritonitis (from leakage or ruptures at staple sites)

or other infection Obstructions caused by scar tissue in the stomach or

bowels

MINOR RISKS Dumping Syndrome (unpleasant but not harmful) Diarrhea and malodorous gas production Lactose intolerance Hair loss (short-term post-surgery) May have to eventually undergo surgical revision Pain post-surgery

History of Bariatric Surgery

Obesity surgery is not a new discipline The earliest Bariatric procedure performed was in 1954 at Minnesota The procedure

was Jejuno-ileal bypass In 1966Gastric Bypass was introduced as a surgical procedure for weight loss at the

University of Iowa In 1977Griffen reported the first Roux-en-Y Gastric Bypass In 1980surgeons with a more conservative approach developed the Vertical Banded

Gastroplasty Other procedures with longer intestinal segment bypass were also introduced such as

Biliopancreatic Diversions These complex procedures are recommended in super-obese patients ie BMIgt60

How does surgery work

RESTRICTIVE - RESTRICT AMOUNT OF FOOD INGESTED Decreases appetitehunger

Early satiety Behavior modification Gastric Banding (Lap Band)

Roux-en Y Gastric bypass (RYGB) Sleeve Gastrectomy

MALABSORPTIVE- LIMITS DIGESTION AND ABSORPTION Decreases length of intestine exposed to digested food

25 of fat is absorbed Behavior modification

Biliopancreatic Diversion Duodenal Switch (BPDDS)

ALL OPERATIONS CAN BE PERFORMED OPEN OR LAPAROSCOPICALLY

Laparoscopic vs Open

OPEN uarr post op pain Longer hospitalizations uarr wound complications

Infection Hernias Seromas

Return to work in 4-8 weeks

LAPAROSCOPIC darr post op pain Early mobility darr Wound complications 2-3 day hospital stay Return to work in 1-3 weeks

1 Nguyen NT et al Accelerated growth of bariatric surgery with the introduction of minimally invasive surgery Arch Surg 20051401198-202

Procedures that are solely restrictive by creating a small gastric pouch of volume 15 to 30 cc amp a degree of outlet obstruction leading to delayed gastric emptying The goal is to reduce oral intake by limiting gastric volume produce early satiety and leave the alimentary canal in continuity minimizing the risks of metabolic complications

1VERTICAL BANDED GASTROPLASTY

2ADJUSTABLE GASTRIC BANDING (LAGB )

3 SLEEVE GASTRECTOMY

4GASTRIC PLICATION

5 INTRA GASTRIC BALLOON (GASTRIC BALLOON)

RESTRICTIVE PROCEDURES

Malabsorption is achieved by creating a short gut syndrome andor by accomplishing distal mixing of bile and pancreatic juice with ingested nutrients thereby reducing absorption Some purely malabsorptive operations are no longer recommended due to their potential hazard to cause serious nutritional deficiencies

1 BILIOPANCREATIC DIVERSION2 THE JEJUNAL-ILEAL BYPASS3 ENDOLUMINAL SLEEVE

MALABSORPTIVE PROCEDURES

MIXED PROCEDURES

1GASTRIC BYPASS ROUX-EN-Y ( RYGBP)

2SLEEVE GASTRECTOMY WITH DUODENAL SWITCH

3IMPLANTABLE 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

The stomach is partitioned along its axis with a non-

adjustable poly-urethane band and with linear amp 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 was practiced in 1980

Vertical Banded Gastroplasty (VBG)

ADJUSTABLE GASTRIC BANDING (LAP BAND SURGERY LAGB)

Restrictive Procedure The procedure was first performed by Cadiere in 1992 but was made popular by Belachew and Legrand in 1993 An inflatable silicone BAND is placed around the top portion of the stomach to form a small stomach pouch amp sewed

This band is connected to a tube that leads to a port above the abdominal muscles placed below the skin (FILL ndash PORT)

During follow up visits we inject or remove saline solution to make the band tighter or looser

Adjustable Gastric Band

bull 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

How does the Band work

Surgery Factors Restriction of meal size Decreased appetite

Patient Factors Decreased calorie intake Increased calorie expenditure

LAP-BAND Adjustability

Unfilled Band Filled Band

Adjustments are made in the office

Complications of Gastric Lap-Band

bull Perforation of Stomachbull Slippagebull Gastric Erosion(much less after Pars flaccida technique) bull Dilated Esophagusbull Tubing access port problemsbull Mal positioningbull Abdominal Painbull Heartburnbull Vomitingbull Inability to Adjust the Bandbull Failure to Lose Weightbull Infection of Systembull Fatigue or malfunction

Advantages

No intestinal surgery No staplingcutting of stomach No nutritional risks Adjustable Reversible Safe

Foreign body Frequent follow-up visits Needs more commitment Easy to cheat

Disadvantages

Comparison of Adjustable Gastric Banding and Vertical Banded Gastroplasty

Laparoscopic adjustable gastric banding Reversible Adjustable Simpler to perform laparoscopically Sustained weight loss of gt50 EBW gt5

years following surgery Complications Gastric prolapse band

erosion rarely gastric perforation and access port complications

Vertical banded gastroplasty Irreversible Non adjustable Technically difficult by laparoscopy Weight loss of 25-50 EBW and weight gain

after 2-3 years Complications suture line disruption gastric

leak weight gain

>

>

Originally used as the first-stage operation for a proposed biliopancreatic diversion with duodenal switch in high-risk patients

The sleeve gastrectomy has caught on as a primary obesity treatment as surgeons are reporting weight loss of 55 of excess body weight past 5 years in some patients

The sleeve gastrectomy is also known as the greater curvature gastrectomy vertical or longitudinal gastrectomy or Pylorus preserving lsquogastric tube creationrsquo

Rapid and less traumatic operation Good resolution of co-morbidities and good weight loss

A further second surgical step is then easily feasible if necessary

SLEEVE GASTRECTOMY

SLEEVE GASTRECTOMY

A sleeve gastrectomy involves resection of

approximately 80 of the greater curvature

side of the stomach

Smaller tubular gastric ldquosleeverdquo created

along the lesser curve that is based on the

lesser curvature blood supply

Ideal approximate capacity of the stomach

after the procedure is about 30- 60 ml pouch

1MECHANICAL RESTRICTION by reducing the volume of the stomach and impairing stomach mobility Also called lsquoFood limitingrsquo operation

2HORMONAL MODIFICATION by removing a great part of the Ghrelin (Hunger Hormone) production tissue

(Ghrelin is a 28 amino-acid-peptide secreted by the oxyntic glands of the gastric fungus It is a potent orexigenic (appetite-stimulating) peptide mediated by the activation of its receptors in the hypothalamus or pituitary area)

The gastric fundus contains 10 to 20 times more ghrelin per one gram of tissue than the duodenum In the SG resection of the fundus removes the major portion of ghrelin release therefore appetite decreases

The sleeve gastrectomy (SG) induces weight loss by 2 mechanisms

>

Intragastric balloon involves placing a deflated balloon into the stomach and then filling it to decrease the amount of gastric space

The balloon can be left in the stomach for a maximum of 6 months and results in an average weight loss of 5ndash9 BMI over half a year

Done endoscopically

The intragastric balloon may be used prior to another bariatric surgery as a step-down procedure

INTRA GASTRIC BALLOON

>

>

The EndoBarrier gastrointestinal liner mimics the effects of gastric bypass surgery

Itrsquos designed to work by inserting a flexible

tube-like barrier into the duodenum amp 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

ENDO BARRIER LINER SYSTEM

B MAL- ABSORPTIVE PROCEDURES

Malabsorptive surgeries rearrange andor remove part of digestive system which then limits the amount of calories and nutrients that body can absorb Treatment with a large malabsorptive component results in the most weight loss but tend to have slightly higher complication rates

1JEJUNAL ILEAL BYPASS ndash no longer performed for high complication rates

2ILEAL TRANSPOSITION- New malabsoptive procedure on trial for treatment of DM type 2 and metabolic disorders

C COMBINATION PROCEDURES RESTRICTIVE + MALABSORBTIVE

1LAP GASTRIC BYPASS ndash ROUX-EN- Y ndash more malabsorption than the restrictive

2MINI- GASTRIC BYPASS- mainly restrictive

3DUODENAL SWITCH ndash the sleeve stomach is the restrictive portion ampthe intestinal bypass (duodenal switch) is the malabsorptive component

When surgery combines both restrictive and malabsorptive techniques it is know as a ldquocombinationrdquo procedure Most types of bariatric surgery carry at least a small element of both components but the following surgeries achieve a notable portion of weight loss from eachhellip

1 LAP GASTRIC BYPASS LGB

The Roux-en-Y gastric bypass(known simply as the LRYGBP) is the most commonly performed procedure

It primarily causesweight loss by restricting thefood intake however there ismore amount of mal absorption that occurs with this operation

GASTRIC BYPASS LRYGBP

bullThe stomach is stapled into2 pieces one small and one large The small piece becomes the ldquonewrdquo stomach pouch

bull The larger portion of the stomach stays in place however will lie dormant for the remainder of the patientrsquos life

GASTRIC BYPASS LGB

bull The small intestine (the jejunum) is divided using a surgical staplerApprox 50-70 cm from the DJ Junction

GASTRIC BYPASS LGB

Y- LIMB BP LIMB

bull The end of the Roux limb is then attached to the newly formed stomach pouch which carries food to the distal intestine

bull The Roux loop is completed by forming a jejunostomy

bull The Y limb or BPD limb carries digestive juices from the pancreas gall bladder liver and duodenum to the intestines

bull The food and the digestive juices mix where the Roux limb and Y limb meet much below say 100-150 cm from DJ

Roux limb or alimentary limb

100-150 cm

How Does the Roux-en-Y Work

Surgery factors restriction of meal size ldquodumping syndromerdquo some malabsorption decreased appetite

Patient factors calorie intake calorie expenditure

bull Most commonly performedbull Most reliable operation for long term weight lossbull Long term weight loss averages 60 to 75 percent of EBWbull Malnutrition is unusualbull Substantial improvement amp resolution in many co-morbid

obesity conditions

ADVANTAGES OF RYGBP

1 Not reversible

2 Mortality 05- 1

3 Perioperative complications 5-10

4 Stricture of gastrojejunostomy-10 (long term)

5 Long term risk of protein amp vitamin deficiency and marginal ulceration of GJA

6Long term risk of intestinal obstruction ndash 2

LAPAROSCOPIC GASTRIC BYPASSCOMPLICATIONS

Biliopancreatic Diversion (BPD)

Primarily malabsorptive but restrictive component also

First Terminal ileum is measured to a length of 50 cms marked with suture

The alimentary tract beyond the proximal part of stomach is rearranged to

include only distal 200 cm of ileum including common channel

Common channel-Distal 50 cm of terminal ileum for absorption of fat and

protein

The proximal end of ileum anastomosed to proximal end of stomach after

performing distal hemigastrectomy

Biliopancreatic Diversion with Duodenal Switch

Modification to lessen high incidence of vit b12 deficiency anastomotic stricture at gastrojejunal anastomosis

This procedure involves a sleeve gastrectomy that is then diverted at the duodenum into the ileum at a point measured proximally from the ileocecal valve (usually 250 cm)

The distal duodenum and jejunum the biliopancreatic limb are then anastomosed to the ileum at a point measured proximally from the ileocecal valve (usually 100 cm)

Common channel is 100cm Entire alimentary tract is 250 cm This is the most aggressive bypass procedure commonly offered today Major difference-Sleeve gastrectomy instead of distal hemigastrectomy

bull Most women regained normal menstrual function and most had documented

spontaneous ovulation

bull Significant improvement in hirsutism androgen profiles and about a 50 reduction in

HOMA-IR

bull Follow up for more than 2 years showed that all women resumed normal menstrual

cycles HbA1C decreased from 82 to 51 in lt 3 months

bull 78 saw improvement in metabolic syndrome amp 48 showed improvement in PCOS

2 ROLE OF BARIATRIC SURGERY IN PCOS PATIENTS

bull Decrease menstrual irregularities bull PCOS women have less hyper androgenism

bull Sex hormone binding globulin increases bull LH and FSH levels have been reported to increase

bull Ovulatory function measured by luteal LH and Progesterone secretion improved bull Leptin levels decrease reflecting improved reproductive metabolic status

bull Subclinical hypothyroidism significantly reduced

THE SAFE TIMING OF PREGNANCYoptimal or minimal time gt12 months after bariatric surgery before becoming pregnant in order to allow the rapid weight loss and metabolic changes to subside

4 BARIATRIC SURGERY IN REPRODUCTIVE WOMEN

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)

The foregut hypothesis theory ndash 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

Effect of Bariatric Surgery on Diabetes Mellitus

Combined Gastric Restriction amp Malabsorption

Operative Risks (vs cholecystectomy)

Perioperative Mortality 1-2 vs 02-08 Early Complications 10 vs 29Late Complications 20 vs 1-2

LimitationsWidening of (unbanded) gastrojejunostomyExpansion of gastric pouch 25 with nearly 100 weight regainAdaptation of limb that receives the food

SUMMARY OF ALL TYPES OF SURGERY

bull LRYGBP ndash worlds best procedure 60-70 WL dumping syndrome malnutrition

bull LAGB- low complications varying range of wt loss frequent post-op visits ( 10)

bull DSBPD- more wt loss high complications good for high BMI gt 50 malabsorption +

bull VBG(vertical band gastroplasty) ndash longest available results good wt loss improved co-morbidities right for some ptsrisks too high to justify rewards

bull SG- needs long term research 1st step procedure low risks higher wt loss lesser complications pouch could Stretch over time long staple line could cause problems in future frequency is accelerating because of technical ease 1st stage procedure before bypass

Post-surgical Complications

Anastomosis leaks or staple line leaks Pulmonary Embolism or DVT Cholelithiasis Stomal ulceration Dumping syndrome Constipation

Anastamosis Leaks

Up to 7-10 days after surgery Most common at gastrojejunostomy enteroenterostomy Roux

limb stump staple line Can lead to peritonitis sepsis possible death Presentation

Tachycardia tachypnea Fever Ab painback pain Pelvic pressure or rebound tenderness

Anastamosis Leaks

Order Gastrograffin upper GI series Subclinical cases

Bowel rest Parenteral nutrition IV antibiotic if H pylori

Clinically suspect leak Laparoscopic evaluation and leak repair

Failure to evaluate is the most common cause of preventable major long-term disability or death in bariatric surgical patients

Pulmonary Embolism

Sudden cause of death up to one month after surgery 20-30 mortality rate High risk may have vena cava filter placement prior to surgery Prophylaxis with compression stockings and LMWH Early ambulation imperitive

Pulmonary Embolism

Presentation Profound hypoxia Hypotension Signs of sepsis

Immediate spiral chest CT Abdominal exploration if too large for machine No pathology start anticoagulation Too largehelliphellipNO SURGERY

Cholelithiasis

Up to 36 of patients within 6 months post-op Bile stasis leads to increased sludge and gallstones Prophylactic cholecystectomy prior to surgery if

evidence of existing sludge or stones Prevent post-operative disease with concurrent bariatric

surgery and cholecystectomy Prophylactic use of urosidol

Expensive and unpalatable

Stomal Ulceration

12-15 within 2-4 mos Post-surgery Etiology

Overabundant acid in pouch leads to excessive acid passing through stoma

Pouch tension and staple line breakdown NSAID use

Presentation Dyspepsia vomiting Epigastric or retrosternal pain

Stomal Ulceration

Treatment PPI carafate Antibiotics if H Pylori Avoid NSAIDS alcohol smoking

If no response to treatment Endoscopy Back to surgery for pouch revision or staple line repair

Dumping Syndrome

More than 15 patients Hypotention Tachycardia Lightheadedness syncope Flushing Abdominal cramping and diarrhea Nausea and vomiting

Dumping Syndrome

Occurs with high dose simple sugar ingestion Sugar in small intestine causes osmotic overload and fluid

shift from blood to intestine Increased intestinal volume leads to watery diarrhea Decreased blood volume leads to systemic changes Patient education

Eat slowly Avoid drinking before during and not until 30 minutes after meals

Constipation

Most common complaint Causes

Dehydration and decreased fluid intake post-operatively Increased metabolic water needs Calcium and iron supplement use following surgery

Treat with increased fluids and stool softeners

Nutritional Consequences

Iron deficiency anemia B12 deficiency Folate deficiency Calcium and Vitamin D deficiency

Not seen with purely restrictive surgeries

Iron deficiency and anemia

Common following RYGB As high as 49 of patients Multifactorial cause

Low gastric acid levels prohibit iron cleavage from food Absorption inhibited because no nutrient exposure to duodenum or

proximal jejunum Decrease in iron-rich food consumption due to intolerance

Treat with oral supplementation of ferrous sulfate or ferrous gluconate

Vitamin B12 deficiency

Up to 70 of patients Lack of hydrochloric acid and pepsin in stomach

Prevents B12 cleavage from food Affects secretion of intrinsic factor thus B12 absorption

Intolerance to meat and milk Oral supplementation usually adequate otherwise IM injections used

Folate Deficiency

40 of gastric bypass patients Complete absorption requires B12 Absorption dependent on HCl and upper 13 stomach Deficiency generally caused by decreased consumption Oral supplementation

Vitamin D and Calcium Deficiency

Vitamin D deficiency is common among obese people Calcium absorption decreased because duodenum is

bypassed Intolerance to dairy foods high in calcium Vitamin D is required for Ca++ absorption Prolonged deficiencies lead to

Bone resorption osteomalacia osteoporosis Treat with calcium citrate supplementation and 2 weekly

doses of Vitamin D

Nutritional Implications of Various Bariatric Surgeries(34)

bull RYGB Malabsorption of Vit B12 Vit B1 (thiamin) Vit D Vit K Folate Iron Calcium

bull LAGB Folic Acid deficiency

bull BPD and BPDDS Vit A D E and K deficiency Protein-Calorie Malnutrition Malabsorption of

Calcium Zinc Selenium Sodium Potassium Chloride Phosphorus Magnesium

Recommended Daily Supplements(4)

Multivitamin with iron (prenatal vitamin will have adeq amount of folic acid)

Calcium (citrate) with vitamin D (1200-1500 mg calcium with 800-1000 IU vitamin D)

Oral vitamin B12 (500-1000 mcg) Iron (65 mgday in elemental form)

Vitamin C (to increase absorption of Iron) Thiamin (10 mgday)

Diet Recommendations(3)

Reduce food volume Chew food very well Slow pace of eating No liquids with meals Encourage fruits and vegetables as diet progresses Include high protein foods (at least 60gday) may need protein

supplements

Diet Progression Gastric Bypass

Stage 1 Clear liquids and protein supplement (1 week)

Stage 2No concentrated sweets low fat puree diet ( 3 weeks)

Stage 3 Regular texture weight reduction diet

Diet Progression Lap - Band

Stage 1 Clear liquids and protein supplement ( 2 weeks)

Stage 2 No concentrated sweets low fat puree diet (2weeks)

Stage 3 Regular texture weight reduction diet

Stage 1

Only clear liquids allowed Avoid sweetened beverages Sip very slowly No straws Avoid caffeinated carbonated and alcoholic beverages STOP drinking if you feel fullness pain or discomfort

Protein supplements

Begin the day after you go home from Hospital

Minimum protein target 70gmsday

May use powder or pre-mixed liquid forms (Whey protein is preferred)

Protein pills may not be used

Vitamin and Mineral Supplements

Gastric bypass patients In addition to eating much less food gastric bypass patients will also

absorb vitamins and minerals differently after surgery They will require daily multivitamin calcium and iron

supplementation for the rest of your life

Vitamin and Mineral Supplements

Lap-Bandreg patients

Require a multivitamin with minerals daily

It may be necessary to take additional vitamins and minerals eg calcium iron folateB1 B12These will be prescribed as needed

Stage 2 dietPUREE

Puree diet

Regular scheduled meals Avoid meal skipping Plan meals in advance Eat Slowly Eat protein foods first Moisten meats Use liquid protein as supplement not as meal replacement

Measure 2 oz portions at each meal eating when full Separate liquids and solids No bread rice or pasta Avoid added sugars and high fat

foods VARIETY

Obesity multidisciplinary team

Surgeon Physician Anesthetist Dietician Specialist bariatric nurse Skilled theatre staff Psychiatrist

Bariatric Surgery and Diabetes

International Diabetes Federation (2011) Journal of Diabetes (3(2011) 261-264) ldquoBariatric surgery is an appropriate treatment of people with T2D and

obesity who are not achieving recommended treatment targets with existing medical therapies especially in the presence of other major comorbiditiesrdquo

lt1 of those eligible actually have WLS for diabetes

Contraindications

Factors that may be considered contraindications include unstable CAD uncontrolled severe OSA uncontrolled psychiatric disorder mental retardation (IQ lt 60) inability to understand the surgery perceived inability to adhere to postoperative restrictions continued drug abuse malignancy with a poor 5-year survival prognosis Cirrhotic liver disease with portal hypertension

Preoperative EvaluationAttention should focus on issues unique to the obese patient

particularly cardiorespiratory status and the airwayConsideration of co morbidities ie hypertension diabetes heart

failure IHD obesity-hypoventilation syndrome metabolic syndrome etc

Results of the sleep study History of previous surgeries their anesthetic challenges need for

ICU admissionCurrent medicationsPatients scheduled for repeat bariatric surgery should be screened

preoperatively for long-term metabolic and nutritional abnormalities

Investigationshellip Recommended preoperative laboratory evaluations include

fasting blood glucose lipid profile electrolytes serum chemistries (to evaluate renal and hepatic function) complete blood count Serum ferritin vitamin B12 thyrotropin amp 25-hydroxyvitamin D

(Miller 7th edition- anesthesia for Bariatic Surgery) ABG measurements help evaluate ventilation as well as the need for perioperative oxygen administration and

postoperative ventilation Routine pulmonary function tests and liver function tests are not cost-effective in asymptomatic obese patients Coaugulation profile ( liver problem repeat surgery orlistat) ECG echocardiography Sleep study if suspected OSA

(Barash 6th edition anesthesia and obesity)

Concurrent Preoperative and Prophylactic Medications

Patients usual medications should be continued until the time of surgery with the possible exception of insulin and oral hypoglycemics

Antibiotic prophylaxis is usually indicated

Obesity itself does not increase the risk for aspiration acid aspiration prophylaxis including H2 receptor agonists or proton pump inhibitors must be considered in patients with identifiable risk for aspiration

Anxiolysis and prophylaxis against deep vein thrombosis (DVT) should be addressed at premedication

DVT consideration Morbid obesity is a major independent risk factor for sudden death from

acute postoperative pulmonary embolism Subcutaneous heparin 5000 IU administered before surgery and repeated every 8 to 12

hours until the patient is fully mobile reduces the risk of DVT LMWH can also be used

Preoperative prophylactic placement of an inferior vena cava filter should be considered in venous stasis disease BMI ge60 truncal obesity and OSA

What Are the Risks

MAJOR RISKS Death (1 of patients die within 30 days) Severe malnutrition (anemia PEM osteomalacia) Peritonitis (from leakage or ruptures at staple sites)

or other infection Obstructions caused by scar tissue in the stomach or

bowels

MINOR RISKS Dumping Syndrome (unpleasant but not harmful) Diarrhea and malodorous gas production Lactose intolerance Hair loss (short-term post-surgery) May have to eventually undergo surgical revision Pain post-surgery

History of Bariatric Surgery

Obesity surgery is not a new discipline The earliest Bariatric procedure performed was in 1954 at Minnesota The procedure

was Jejuno-ileal bypass In 1966Gastric Bypass was introduced as a surgical procedure for weight loss at the

University of Iowa In 1977Griffen reported the first Roux-en-Y Gastric Bypass In 1980surgeons with a more conservative approach developed the Vertical Banded

Gastroplasty Other procedures with longer intestinal segment bypass were also introduced such as

Biliopancreatic Diversions These complex procedures are recommended in super-obese patients ie BMIgt60

How does surgery work

RESTRICTIVE - RESTRICT AMOUNT OF FOOD INGESTED Decreases appetitehunger

Early satiety Behavior modification Gastric Banding (Lap Band)

Roux-en Y Gastric bypass (RYGB) Sleeve Gastrectomy

MALABSORPTIVE- LIMITS DIGESTION AND ABSORPTION Decreases length of intestine exposed to digested food

25 of fat is absorbed Behavior modification

Biliopancreatic Diversion Duodenal Switch (BPDDS)

ALL OPERATIONS CAN BE PERFORMED OPEN OR LAPAROSCOPICALLY

Laparoscopic vs Open

OPEN uarr post op pain Longer hospitalizations uarr wound complications

Infection Hernias Seromas

Return to work in 4-8 weeks

LAPAROSCOPIC darr post op pain Early mobility darr Wound complications 2-3 day hospital stay Return to work in 1-3 weeks

1 Nguyen NT et al Accelerated growth of bariatric surgery with the introduction of minimally invasive surgery Arch Surg 20051401198-202

Procedures that are solely restrictive by creating a small gastric pouch of volume 15 to 30 cc amp a degree of outlet obstruction leading to delayed gastric emptying The goal is to reduce oral intake by limiting gastric volume produce early satiety and leave the alimentary canal in continuity minimizing the risks of metabolic complications

1VERTICAL BANDED GASTROPLASTY

2ADJUSTABLE GASTRIC BANDING (LAGB )

3 SLEEVE GASTRECTOMY

4GASTRIC PLICATION

5 INTRA GASTRIC BALLOON (GASTRIC BALLOON)

RESTRICTIVE PROCEDURES

Malabsorption is achieved by creating a short gut syndrome andor by accomplishing distal mixing of bile and pancreatic juice with ingested nutrients thereby reducing absorption Some purely malabsorptive operations are no longer recommended due to their potential hazard to cause serious nutritional deficiencies

1 BILIOPANCREATIC DIVERSION2 THE JEJUNAL-ILEAL BYPASS3 ENDOLUMINAL SLEEVE

MALABSORPTIVE PROCEDURES

MIXED PROCEDURES

1GASTRIC BYPASS ROUX-EN-Y ( RYGBP)

2SLEEVE GASTRECTOMY WITH DUODENAL SWITCH

3IMPLANTABLE 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

The stomach is partitioned along its axis with a non-

adjustable poly-urethane band and with linear amp 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 was practiced in 1980

Vertical Banded Gastroplasty (VBG)

ADJUSTABLE GASTRIC BANDING (LAP BAND SURGERY LAGB)

Restrictive Procedure The procedure was first performed by Cadiere in 1992 but was made popular by Belachew and Legrand in 1993 An inflatable silicone BAND is placed around the top portion of the stomach to form a small stomach pouch amp sewed

This band is connected to a tube that leads to a port above the abdominal muscles placed below the skin (FILL ndash PORT)

During follow up visits we inject or remove saline solution to make the band tighter or looser

Adjustable Gastric Band

bull 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

How does the Band work

Surgery Factors Restriction of meal size Decreased appetite

Patient Factors Decreased calorie intake Increased calorie expenditure

LAP-BAND Adjustability

Unfilled Band Filled Band

Adjustments are made in the office

Complications of Gastric Lap-Band

bull Perforation of Stomachbull Slippagebull Gastric Erosion(much less after Pars flaccida technique) bull Dilated Esophagusbull Tubing access port problemsbull Mal positioningbull Abdominal Painbull Heartburnbull Vomitingbull Inability to Adjust the Bandbull Failure to Lose Weightbull Infection of Systembull Fatigue or malfunction

Advantages

No intestinal surgery No staplingcutting of stomach No nutritional risks Adjustable Reversible Safe

Foreign body Frequent follow-up visits Needs more commitment Easy to cheat

Disadvantages

Comparison of Adjustable Gastric Banding and Vertical Banded Gastroplasty

Laparoscopic adjustable gastric banding Reversible Adjustable Simpler to perform laparoscopically Sustained weight loss of gt50 EBW gt5

years following surgery Complications Gastric prolapse band

erosion rarely gastric perforation and access port complications

Vertical banded gastroplasty Irreversible Non adjustable Technically difficult by laparoscopy Weight loss of 25-50 EBW and weight gain

after 2-3 years Complications suture line disruption gastric

leak weight gain

>

>

Originally used as the first-stage operation for a proposed biliopancreatic diversion with duodenal switch in high-risk patients

The sleeve gastrectomy has caught on as a primary obesity treatment as surgeons are reporting weight loss of 55 of excess body weight past 5 years in some patients

The sleeve gastrectomy is also known as the greater curvature gastrectomy vertical or longitudinal gastrectomy or Pylorus preserving lsquogastric tube creationrsquo

Rapid and less traumatic operation Good resolution of co-morbidities and good weight loss

A further second surgical step is then easily feasible if necessary

SLEEVE GASTRECTOMY

SLEEVE GASTRECTOMY

A sleeve gastrectomy involves resection of

approximately 80 of the greater curvature

side of the stomach

Smaller tubular gastric ldquosleeverdquo created

along the lesser curve that is based on the

lesser curvature blood supply

Ideal approximate capacity of the stomach

after the procedure is about 30- 60 ml pouch

1MECHANICAL RESTRICTION by reducing the volume of the stomach and impairing stomach mobility Also called lsquoFood limitingrsquo operation

2HORMONAL MODIFICATION by removing a great part of the Ghrelin (Hunger Hormone) production tissue

(Ghrelin is a 28 amino-acid-peptide secreted by the oxyntic glands of the gastric fungus It is a potent orexigenic (appetite-stimulating) peptide mediated by the activation of its receptors in the hypothalamus or pituitary area)

The gastric fundus contains 10 to 20 times more ghrelin per one gram of tissue than the duodenum In the SG resection of the fundus removes the major portion of ghrelin release therefore appetite decreases

The sleeve gastrectomy (SG) induces weight loss by 2 mechanisms

>

Intragastric balloon involves placing a deflated balloon into the stomach and then filling it to decrease the amount of gastric space

The balloon can be left in the stomach for a maximum of 6 months and results in an average weight loss of 5ndash9 BMI over half a year

Done endoscopically

The intragastric balloon may be used prior to another bariatric surgery as a step-down procedure

INTRA GASTRIC BALLOON

>

>

The EndoBarrier gastrointestinal liner mimics the effects of gastric bypass surgery

Itrsquos designed to work by inserting a flexible

tube-like barrier into the duodenum amp 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

ENDO BARRIER LINER SYSTEM

B MAL- ABSORPTIVE PROCEDURES

Malabsorptive surgeries rearrange andor remove part of digestive system which then limits the amount of calories and nutrients that body can absorb Treatment with a large malabsorptive component results in the most weight loss but tend to have slightly higher complication rates

1JEJUNAL ILEAL BYPASS ndash no longer performed for high complication rates

2ILEAL TRANSPOSITION- New malabsoptive procedure on trial for treatment of DM type 2 and metabolic disorders

C COMBINATION PROCEDURES RESTRICTIVE + MALABSORBTIVE

1LAP GASTRIC BYPASS ndash ROUX-EN- Y ndash more malabsorption than the restrictive

2MINI- GASTRIC BYPASS- mainly restrictive

3DUODENAL SWITCH ndash the sleeve stomach is the restrictive portion ampthe intestinal bypass (duodenal switch) is the malabsorptive component

When surgery combines both restrictive and malabsorptive techniques it is know as a ldquocombinationrdquo procedure Most types of bariatric surgery carry at least a small element of both components but the following surgeries achieve a notable portion of weight loss from eachhellip

1 LAP GASTRIC BYPASS LGB

The Roux-en-Y gastric bypass(known simply as the LRYGBP) is the most commonly performed procedure

It primarily causesweight loss by restricting thefood intake however there ismore amount of mal absorption that occurs with this operation

GASTRIC BYPASS LRYGBP

bullThe stomach is stapled into2 pieces one small and one large The small piece becomes the ldquonewrdquo stomach pouch

bull The larger portion of the stomach stays in place however will lie dormant for the remainder of the patientrsquos life

GASTRIC BYPASS LGB

bull The small intestine (the jejunum) is divided using a surgical staplerApprox 50-70 cm from the DJ Junction

GASTRIC BYPASS LGB

Y- LIMB BP LIMB

bull The end of the Roux limb is then attached to the newly formed stomach pouch which carries food to the distal intestine

bull The Roux loop is completed by forming a jejunostomy

bull The Y limb or BPD limb carries digestive juices from the pancreas gall bladder liver and duodenum to the intestines

bull The food and the digestive juices mix where the Roux limb and Y limb meet much below say 100-150 cm from DJ

Roux limb or alimentary limb

100-150 cm

How Does the Roux-en-Y Work

Surgery factors restriction of meal size ldquodumping syndromerdquo some malabsorption decreased appetite

Patient factors calorie intake calorie expenditure

bull Most commonly performedbull Most reliable operation for long term weight lossbull Long term weight loss averages 60 to 75 percent of EBWbull Malnutrition is unusualbull Substantial improvement amp resolution in many co-morbid

obesity conditions

ADVANTAGES OF RYGBP

1 Not reversible

2 Mortality 05- 1

3 Perioperative complications 5-10

4 Stricture of gastrojejunostomy-10 (long term)

5 Long term risk of protein amp vitamin deficiency and marginal ulceration of GJA

6Long term risk of intestinal obstruction ndash 2

LAPAROSCOPIC GASTRIC BYPASSCOMPLICATIONS

Biliopancreatic Diversion (BPD)

Primarily malabsorptive but restrictive component also

First Terminal ileum is measured to a length of 50 cms marked with suture

The alimentary tract beyond the proximal part of stomach is rearranged to

include only distal 200 cm of ileum including common channel

Common channel-Distal 50 cm of terminal ileum for absorption of fat and

protein

The proximal end of ileum anastomosed to proximal end of stomach after

performing distal hemigastrectomy

Biliopancreatic Diversion with Duodenal Switch

Modification to lessen high incidence of vit b12 deficiency anastomotic stricture at gastrojejunal anastomosis

This procedure involves a sleeve gastrectomy that is then diverted at the duodenum into the ileum at a point measured proximally from the ileocecal valve (usually 250 cm)

The distal duodenum and jejunum the biliopancreatic limb are then anastomosed to the ileum at a point measured proximally from the ileocecal valve (usually 100 cm)

Common channel is 100cm Entire alimentary tract is 250 cm This is the most aggressive bypass procedure commonly offered today Major difference-Sleeve gastrectomy instead of distal hemigastrectomy

bull Most women regained normal menstrual function and most had documented

spontaneous ovulation

bull Significant improvement in hirsutism androgen profiles and about a 50 reduction in

HOMA-IR

bull Follow up for more than 2 years showed that all women resumed normal menstrual

cycles HbA1C decreased from 82 to 51 in lt 3 months

bull 78 saw improvement in metabolic syndrome amp 48 showed improvement in PCOS

2 ROLE OF BARIATRIC SURGERY IN PCOS PATIENTS

bull Decrease menstrual irregularities bull PCOS women have less hyper androgenism

bull Sex hormone binding globulin increases bull LH and FSH levels have been reported to increase

bull Ovulatory function measured by luteal LH and Progesterone secretion improved bull Leptin levels decrease reflecting improved reproductive metabolic status

bull Subclinical hypothyroidism significantly reduced

THE SAFE TIMING OF PREGNANCYoptimal or minimal time gt12 months after bariatric surgery before becoming pregnant in order to allow the rapid weight loss and metabolic changes to subside

4 BARIATRIC SURGERY IN REPRODUCTIVE WOMEN

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)

The foregut hypothesis theory ndash 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

Effect of Bariatric Surgery on Diabetes Mellitus

Combined Gastric Restriction amp Malabsorption

Operative Risks (vs cholecystectomy)

Perioperative Mortality 1-2 vs 02-08 Early Complications 10 vs 29Late Complications 20 vs 1-2

LimitationsWidening of (unbanded) gastrojejunostomyExpansion of gastric pouch 25 with nearly 100 weight regainAdaptation of limb that receives the food

SUMMARY OF ALL TYPES OF SURGERY

bull LRYGBP ndash worlds best procedure 60-70 WL dumping syndrome malnutrition

bull LAGB- low complications varying range of wt loss frequent post-op visits ( 10)

bull DSBPD- more wt loss high complications good for high BMI gt 50 malabsorption +

bull VBG(vertical band gastroplasty) ndash longest available results good wt loss improved co-morbidities right for some ptsrisks too high to justify rewards

bull SG- needs long term research 1st step procedure low risks higher wt loss lesser complications pouch could Stretch over time long staple line could cause problems in future frequency is accelerating because of technical ease 1st stage procedure before bypass

Post-surgical Complications

Anastomosis leaks or staple line leaks Pulmonary Embolism or DVT Cholelithiasis Stomal ulceration Dumping syndrome Constipation

Anastamosis Leaks

Up to 7-10 days after surgery Most common at gastrojejunostomy enteroenterostomy Roux

limb stump staple line Can lead to peritonitis sepsis possible death Presentation

Tachycardia tachypnea Fever Ab painback pain Pelvic pressure or rebound tenderness

Anastamosis Leaks

Order Gastrograffin upper GI series Subclinical cases

Bowel rest Parenteral nutrition IV antibiotic if H pylori

Clinically suspect leak Laparoscopic evaluation and leak repair

Failure to evaluate is the most common cause of preventable major long-term disability or death in bariatric surgical patients

Pulmonary Embolism

Sudden cause of death up to one month after surgery 20-30 mortality rate High risk may have vena cava filter placement prior to surgery Prophylaxis with compression stockings and LMWH Early ambulation imperitive

Pulmonary Embolism

Presentation Profound hypoxia Hypotension Signs of sepsis

Immediate spiral chest CT Abdominal exploration if too large for machine No pathology start anticoagulation Too largehelliphellipNO SURGERY

Cholelithiasis

Up to 36 of patients within 6 months post-op Bile stasis leads to increased sludge and gallstones Prophylactic cholecystectomy prior to surgery if

evidence of existing sludge or stones Prevent post-operative disease with concurrent bariatric

surgery and cholecystectomy Prophylactic use of urosidol

Expensive and unpalatable

Stomal Ulceration

12-15 within 2-4 mos Post-surgery Etiology

Overabundant acid in pouch leads to excessive acid passing through stoma

Pouch tension and staple line breakdown NSAID use

Presentation Dyspepsia vomiting Epigastric or retrosternal pain

Stomal Ulceration

Treatment PPI carafate Antibiotics if H Pylori Avoid NSAIDS alcohol smoking

If no response to treatment Endoscopy Back to surgery for pouch revision or staple line repair

Dumping Syndrome

More than 15 patients Hypotention Tachycardia Lightheadedness syncope Flushing Abdominal cramping and diarrhea Nausea and vomiting

Dumping Syndrome

Occurs with high dose simple sugar ingestion Sugar in small intestine causes osmotic overload and fluid

shift from blood to intestine Increased intestinal volume leads to watery diarrhea Decreased blood volume leads to systemic changes Patient education

Eat slowly Avoid drinking before during and not until 30 minutes after meals

Constipation

Most common complaint Causes

Dehydration and decreased fluid intake post-operatively Increased metabolic water needs Calcium and iron supplement use following surgery

Treat with increased fluids and stool softeners

Nutritional Consequences

Iron deficiency anemia B12 deficiency Folate deficiency Calcium and Vitamin D deficiency

Not seen with purely restrictive surgeries

Iron deficiency and anemia

Common following RYGB As high as 49 of patients Multifactorial cause

Low gastric acid levels prohibit iron cleavage from food Absorption inhibited because no nutrient exposure to duodenum or

proximal jejunum Decrease in iron-rich food consumption due to intolerance

Treat with oral supplementation of ferrous sulfate or ferrous gluconate

Vitamin B12 deficiency

Up to 70 of patients Lack of hydrochloric acid and pepsin in stomach

Prevents B12 cleavage from food Affects secretion of intrinsic factor thus B12 absorption

Intolerance to meat and milk Oral supplementation usually adequate otherwise IM injections used

Folate Deficiency

40 of gastric bypass patients Complete absorption requires B12 Absorption dependent on HCl and upper 13 stomach Deficiency generally caused by decreased consumption Oral supplementation

Vitamin D and Calcium Deficiency

Vitamin D deficiency is common among obese people Calcium absorption decreased because duodenum is

bypassed Intolerance to dairy foods high in calcium Vitamin D is required for Ca++ absorption Prolonged deficiencies lead to

Bone resorption osteomalacia osteoporosis Treat with calcium citrate supplementation and 2 weekly

doses of Vitamin D

Nutritional Implications of Various Bariatric Surgeries(34)

bull RYGB Malabsorption of Vit B12 Vit B1 (thiamin) Vit D Vit K Folate Iron Calcium

bull LAGB Folic Acid deficiency

bull BPD and BPDDS Vit A D E and K deficiency Protein-Calorie Malnutrition Malabsorption of

Calcium Zinc Selenium Sodium Potassium Chloride Phosphorus Magnesium

Recommended Daily Supplements(4)

Multivitamin with iron (prenatal vitamin will have adeq amount of folic acid)

Calcium (citrate) with vitamin D (1200-1500 mg calcium with 800-1000 IU vitamin D)

Oral vitamin B12 (500-1000 mcg) Iron (65 mgday in elemental form)

Vitamin C (to increase absorption of Iron) Thiamin (10 mgday)

Diet Recommendations(3)

Reduce food volume Chew food very well Slow pace of eating No liquids with meals Encourage fruits and vegetables as diet progresses Include high protein foods (at least 60gday) may need protein

supplements

Diet Progression Gastric Bypass

Stage 1 Clear liquids and protein supplement (1 week)

Stage 2No concentrated sweets low fat puree diet ( 3 weeks)

Stage 3 Regular texture weight reduction diet

Diet Progression Lap - Band

Stage 1 Clear liquids and protein supplement ( 2 weeks)

Stage 2 No concentrated sweets low fat puree diet (2weeks)

Stage 3 Regular texture weight reduction diet

Stage 1

Only clear liquids allowed Avoid sweetened beverages Sip very slowly No straws Avoid caffeinated carbonated and alcoholic beverages STOP drinking if you feel fullness pain or discomfort

Protein supplements

Begin the day after you go home from Hospital

Minimum protein target 70gmsday

May use powder or pre-mixed liquid forms (Whey protein is preferred)

Protein pills may not be used

Vitamin and Mineral Supplements

Gastric bypass patients In addition to eating much less food gastric bypass patients will also

absorb vitamins and minerals differently after surgery They will require daily multivitamin calcium and iron

supplementation for the rest of your life

Vitamin and Mineral Supplements

Lap-Bandreg patients

Require a multivitamin with minerals daily

It may be necessary to take additional vitamins and minerals eg calcium iron folateB1 B12These will be prescribed as needed

Stage 2 dietPUREE

Puree diet

Regular scheduled meals Avoid meal skipping Plan meals in advance Eat Slowly Eat protein foods first Moisten meats Use liquid protein as supplement not as meal replacement

Measure 2 oz portions at each meal eating when full Separate liquids and solids No bread rice or pasta Avoid added sugars and high fat

foods VARIETY

Bariatric Surgery and Diabetes

International Diabetes Federation (2011) Journal of Diabetes (3(2011) 261-264) ldquoBariatric surgery is an appropriate treatment of people with T2D and

obesity who are not achieving recommended treatment targets with existing medical therapies especially in the presence of other major comorbiditiesrdquo

lt1 of those eligible actually have WLS for diabetes

Contraindications

Factors that may be considered contraindications include unstable CAD uncontrolled severe OSA uncontrolled psychiatric disorder mental retardation (IQ lt 60) inability to understand the surgery perceived inability to adhere to postoperative restrictions continued drug abuse malignancy with a poor 5-year survival prognosis Cirrhotic liver disease with portal hypertension

Preoperative EvaluationAttention should focus on issues unique to the obese patient

particularly cardiorespiratory status and the airwayConsideration of co morbidities ie hypertension diabetes heart

failure IHD obesity-hypoventilation syndrome metabolic syndrome etc

Results of the sleep study History of previous surgeries their anesthetic challenges need for

ICU admissionCurrent medicationsPatients scheduled for repeat bariatric surgery should be screened

preoperatively for long-term metabolic and nutritional abnormalities

Investigationshellip Recommended preoperative laboratory evaluations include

fasting blood glucose lipid profile electrolytes serum chemistries (to evaluate renal and hepatic function) complete blood count Serum ferritin vitamin B12 thyrotropin amp 25-hydroxyvitamin D

(Miller 7th edition- anesthesia for Bariatic Surgery) ABG measurements help evaluate ventilation as well as the need for perioperative oxygen administration and

postoperative ventilation Routine pulmonary function tests and liver function tests are not cost-effective in asymptomatic obese patients Coaugulation profile ( liver problem repeat surgery orlistat) ECG echocardiography Sleep study if suspected OSA

(Barash 6th edition anesthesia and obesity)

Concurrent Preoperative and Prophylactic Medications

Patients usual medications should be continued until the time of surgery with the possible exception of insulin and oral hypoglycemics

Antibiotic prophylaxis is usually indicated

Obesity itself does not increase the risk for aspiration acid aspiration prophylaxis including H2 receptor agonists or proton pump inhibitors must be considered in patients with identifiable risk for aspiration

Anxiolysis and prophylaxis against deep vein thrombosis (DVT) should be addressed at premedication

DVT consideration Morbid obesity is a major independent risk factor for sudden death from

acute postoperative pulmonary embolism Subcutaneous heparin 5000 IU administered before surgery and repeated every 8 to 12

hours until the patient is fully mobile reduces the risk of DVT LMWH can also be used

Preoperative prophylactic placement of an inferior vena cava filter should be considered in venous stasis disease BMI ge60 truncal obesity and OSA

What Are the Risks

MAJOR RISKS Death (1 of patients die within 30 days) Severe malnutrition (anemia PEM osteomalacia) Peritonitis (from leakage or ruptures at staple sites)

or other infection Obstructions caused by scar tissue in the stomach or

bowels

MINOR RISKS Dumping Syndrome (unpleasant but not harmful) Diarrhea and malodorous gas production Lactose intolerance Hair loss (short-term post-surgery) May have to eventually undergo surgical revision Pain post-surgery

History of Bariatric Surgery

Obesity surgery is not a new discipline The earliest Bariatric procedure performed was in 1954 at Minnesota The procedure

was Jejuno-ileal bypass In 1966Gastric Bypass was introduced as a surgical procedure for weight loss at the

University of Iowa In 1977Griffen reported the first Roux-en-Y Gastric Bypass In 1980surgeons with a more conservative approach developed the Vertical Banded

Gastroplasty Other procedures with longer intestinal segment bypass were also introduced such as

Biliopancreatic Diversions These complex procedures are recommended in super-obese patients ie BMIgt60

How does surgery work

RESTRICTIVE - RESTRICT AMOUNT OF FOOD INGESTED Decreases appetitehunger

Early satiety Behavior modification Gastric Banding (Lap Band)

Roux-en Y Gastric bypass (RYGB) Sleeve Gastrectomy

MALABSORPTIVE- LIMITS DIGESTION AND ABSORPTION Decreases length of intestine exposed to digested food

25 of fat is absorbed Behavior modification

Biliopancreatic Diversion Duodenal Switch (BPDDS)

ALL OPERATIONS CAN BE PERFORMED OPEN OR LAPAROSCOPICALLY

Laparoscopic vs Open

OPEN uarr post op pain Longer hospitalizations uarr wound complications

Infection Hernias Seromas

Return to work in 4-8 weeks

LAPAROSCOPIC darr post op pain Early mobility darr Wound complications 2-3 day hospital stay Return to work in 1-3 weeks

1 Nguyen NT et al Accelerated growth of bariatric surgery with the introduction of minimally invasive surgery Arch Surg 20051401198-202

Procedures that are solely restrictive by creating a small gastric pouch of volume 15 to 30 cc amp a degree of outlet obstruction leading to delayed gastric emptying The goal is to reduce oral intake by limiting gastric volume produce early satiety and leave the alimentary canal in continuity minimizing the risks of metabolic complications

1VERTICAL BANDED GASTROPLASTY

2ADJUSTABLE GASTRIC BANDING (LAGB )

3 SLEEVE GASTRECTOMY

4GASTRIC PLICATION

5 INTRA GASTRIC BALLOON (GASTRIC BALLOON)

RESTRICTIVE PROCEDURES

Malabsorption is achieved by creating a short gut syndrome andor by accomplishing distal mixing of bile and pancreatic juice with ingested nutrients thereby reducing absorption Some purely malabsorptive operations are no longer recommended due to their potential hazard to cause serious nutritional deficiencies

1 BILIOPANCREATIC DIVERSION2 THE JEJUNAL-ILEAL BYPASS3 ENDOLUMINAL SLEEVE

MALABSORPTIVE PROCEDURES

MIXED PROCEDURES

1GASTRIC BYPASS ROUX-EN-Y ( RYGBP)

2SLEEVE GASTRECTOMY WITH DUODENAL SWITCH

3IMPLANTABLE 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

The stomach is partitioned along its axis with a non-

adjustable poly-urethane band and with linear amp 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 was practiced in 1980

Vertical Banded Gastroplasty (VBG)

ADJUSTABLE GASTRIC BANDING (LAP BAND SURGERY LAGB)

Restrictive Procedure The procedure was first performed by Cadiere in 1992 but was made popular by Belachew and Legrand in 1993 An inflatable silicone BAND is placed around the top portion of the stomach to form a small stomach pouch amp sewed

This band is connected to a tube that leads to a port above the abdominal muscles placed below the skin (FILL ndash PORT)

During follow up visits we inject or remove saline solution to make the band tighter or looser

Adjustable Gastric Band

bull 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

How does the Band work

Surgery Factors Restriction of meal size Decreased appetite

Patient Factors Decreased calorie intake Increased calorie expenditure

LAP-BAND Adjustability

Unfilled Band Filled Band

Adjustments are made in the office

Complications of Gastric Lap-Band

bull Perforation of Stomachbull Slippagebull Gastric Erosion(much less after Pars flaccida technique) bull Dilated Esophagusbull Tubing access port problemsbull Mal positioningbull Abdominal Painbull Heartburnbull Vomitingbull Inability to Adjust the Bandbull Failure to Lose Weightbull Infection of Systembull Fatigue or malfunction

Advantages

No intestinal surgery No staplingcutting of stomach No nutritional risks Adjustable Reversible Safe

Foreign body Frequent follow-up visits Needs more commitment Easy to cheat

Disadvantages

Comparison of Adjustable Gastric Banding and Vertical Banded Gastroplasty

Laparoscopic adjustable gastric banding Reversible Adjustable Simpler to perform laparoscopically Sustained weight loss of gt50 EBW gt5

years following surgery Complications Gastric prolapse band

erosion rarely gastric perforation and access port complications

Vertical banded gastroplasty Irreversible Non adjustable Technically difficult by laparoscopy Weight loss of 25-50 EBW and weight gain

after 2-3 years Complications suture line disruption gastric

leak weight gain

>

>

Originally used as the first-stage operation for a proposed biliopancreatic diversion with duodenal switch in high-risk patients

The sleeve gastrectomy has caught on as a primary obesity treatment as surgeons are reporting weight loss of 55 of excess body weight past 5 years in some patients

The sleeve gastrectomy is also known as the greater curvature gastrectomy vertical or longitudinal gastrectomy or Pylorus preserving lsquogastric tube creationrsquo

Rapid and less traumatic operation Good resolution of co-morbidities and good weight loss

A further second surgical step is then easily feasible if necessary

SLEEVE GASTRECTOMY

SLEEVE GASTRECTOMY

A sleeve gastrectomy involves resection of

approximately 80 of the greater curvature

side of the stomach

Smaller tubular gastric ldquosleeverdquo created

along the lesser curve that is based on the

lesser curvature blood supply

Ideal approximate capacity of the stomach

after the procedure is about 30- 60 ml pouch

1MECHANICAL RESTRICTION by reducing the volume of the stomach and impairing stomach mobility Also called lsquoFood limitingrsquo operation

2HORMONAL MODIFICATION by removing a great part of the Ghrelin (Hunger Hormone) production tissue

(Ghrelin is a 28 amino-acid-peptide secreted by the oxyntic glands of the gastric fungus It is a potent orexigenic (appetite-stimulating) peptide mediated by the activation of its receptors in the hypothalamus or pituitary area)

The gastric fundus contains 10 to 20 times more ghrelin per one gram of tissue than the duodenum In the SG resection of the fundus removes the major portion of ghrelin release therefore appetite decreases

The sleeve gastrectomy (SG) induces weight loss by 2 mechanisms

>

Intragastric balloon involves placing a deflated balloon into the stomach and then filling it to decrease the amount of gastric space

The balloon can be left in the stomach for a maximum of 6 months and results in an average weight loss of 5ndash9 BMI over half a year

Done endoscopically

The intragastric balloon may be used prior to another bariatric surgery as a step-down procedure

INTRA GASTRIC BALLOON

>

>

The EndoBarrier gastrointestinal liner mimics the effects of gastric bypass surgery

Itrsquos designed to work by inserting a flexible

tube-like barrier into the duodenum amp 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

ENDO BARRIER LINER SYSTEM

B MAL- ABSORPTIVE PROCEDURES

Malabsorptive surgeries rearrange andor remove part of digestive system which then limits the amount of calories and nutrients that body can absorb Treatment with a large malabsorptive component results in the most weight loss but tend to have slightly higher complication rates

1JEJUNAL ILEAL BYPASS ndash no longer performed for high complication rates

2ILEAL TRANSPOSITION- New malabsoptive procedure on trial for treatment of DM type 2 and metabolic disorders

C COMBINATION PROCEDURES RESTRICTIVE + MALABSORBTIVE

1LAP GASTRIC BYPASS ndash ROUX-EN- Y ndash more malabsorption than the restrictive

2MINI- GASTRIC BYPASS- mainly restrictive

3DUODENAL SWITCH ndash the sleeve stomach is the restrictive portion ampthe intestinal bypass (duodenal switch) is the malabsorptive component

When surgery combines both restrictive and malabsorptive techniques it is know as a ldquocombinationrdquo procedure Most types of bariatric surgery carry at least a small element of both components but the following surgeries achieve a notable portion of weight loss from eachhellip

1 LAP GASTRIC BYPASS LGB

The Roux-en-Y gastric bypass(known simply as the LRYGBP) is the most commonly performed procedure

It primarily causesweight loss by restricting thefood intake however there ismore amount of mal absorption that occurs with this operation

GASTRIC BYPASS LRYGBP

bullThe stomach is stapled into2 pieces one small and one large The small piece becomes the ldquonewrdquo stomach pouch

bull The larger portion of the stomach stays in place however will lie dormant for the remainder of the patientrsquos life

GASTRIC BYPASS LGB

bull The small intestine (the jejunum) is divided using a surgical staplerApprox 50-70 cm from the DJ Junction

GASTRIC BYPASS LGB

Y- LIMB BP LIMB

bull The end of the Roux limb is then attached to the newly formed stomach pouch which carries food to the distal intestine

bull The Roux loop is completed by forming a jejunostomy

bull The Y limb or BPD limb carries digestive juices from the pancreas gall bladder liver and duodenum to the intestines

bull The food and the digestive juices mix where the Roux limb and Y limb meet much below say 100-150 cm from DJ

Roux limb or alimentary limb

100-150 cm

How Does the Roux-en-Y Work

Surgery factors restriction of meal size ldquodumping syndromerdquo some malabsorption decreased appetite

Patient factors calorie intake calorie expenditure

bull Most commonly performedbull Most reliable operation for long term weight lossbull Long term weight loss averages 60 to 75 percent of EBWbull Malnutrition is unusualbull Substantial improvement amp resolution in many co-morbid

obesity conditions

ADVANTAGES OF RYGBP

1 Not reversible

2 Mortality 05- 1

3 Perioperative complications 5-10

4 Stricture of gastrojejunostomy-10 (long term)

5 Long term risk of protein amp vitamin deficiency and marginal ulceration of GJA

6Long term risk of intestinal obstruction ndash 2

LAPAROSCOPIC GASTRIC BYPASSCOMPLICATIONS

Biliopancreatic Diversion (BPD)

Primarily malabsorptive but restrictive component also

First Terminal ileum is measured to a length of 50 cms marked with suture

The alimentary tract beyond the proximal part of stomach is rearranged to

include only distal 200 cm of ileum including common channel

Common channel-Distal 50 cm of terminal ileum for absorption of fat and

protein

The proximal end of ileum anastomosed to proximal end of stomach after

performing distal hemigastrectomy

Biliopancreatic Diversion with Duodenal Switch

Modification to lessen high incidence of vit b12 deficiency anastomotic stricture at gastrojejunal anastomosis

This procedure involves a sleeve gastrectomy that is then diverted at the duodenum into the ileum at a point measured proximally from the ileocecal valve (usually 250 cm)

The distal duodenum and jejunum the biliopancreatic limb are then anastomosed to the ileum at a point measured proximally from the ileocecal valve (usually 100 cm)

Common channel is 100cm Entire alimentary tract is 250 cm This is the most aggressive bypass procedure commonly offered today Major difference-Sleeve gastrectomy instead of distal hemigastrectomy

bull Most women regained normal menstrual function and most had documented

spontaneous ovulation

bull Significant improvement in hirsutism androgen profiles and about a 50 reduction in

HOMA-IR

bull Follow up for more than 2 years showed that all women resumed normal menstrual

cycles HbA1C decreased from 82 to 51 in lt 3 months

bull 78 saw improvement in metabolic syndrome amp 48 showed improvement in PCOS

2 ROLE OF BARIATRIC SURGERY IN PCOS PATIENTS

bull Decrease menstrual irregularities bull PCOS women have less hyper androgenism

bull Sex hormone binding globulin increases bull LH and FSH levels have been reported to increase

bull Ovulatory function measured by luteal LH and Progesterone secretion improved bull Leptin levels decrease reflecting improved reproductive metabolic status

bull Subclinical hypothyroidism significantly reduced

THE SAFE TIMING OF PREGNANCYoptimal or minimal time gt12 months after bariatric surgery before becoming pregnant in order to allow the rapid weight loss and metabolic changes to subside

4 BARIATRIC SURGERY IN REPRODUCTIVE WOMEN

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)

The foregut hypothesis theory ndash 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

Effect of Bariatric Surgery on Diabetes Mellitus

Combined Gastric Restriction amp Malabsorption

Operative Risks (vs cholecystectomy)

Perioperative Mortality 1-2 vs 02-08 Early Complications 10 vs 29Late Complications 20 vs 1-2

LimitationsWidening of (unbanded) gastrojejunostomyExpansion of gastric pouch 25 with nearly 100 weight regainAdaptation of limb that receives the food

SUMMARY OF ALL TYPES OF SURGERY

bull LRYGBP ndash worlds best procedure 60-70 WL dumping syndrome malnutrition

bull LAGB- low complications varying range of wt loss frequent post-op visits ( 10)

bull DSBPD- more wt loss high complications good for high BMI gt 50 malabsorption +

bull VBG(vertical band gastroplasty) ndash longest available results good wt loss improved co-morbidities right for some ptsrisks too high to justify rewards

bull SG- needs long term research 1st step procedure low risks higher wt loss lesser complications pouch could Stretch over time long staple line could cause problems in future frequency is accelerating because of technical ease 1st stage procedure before bypass

Post-surgical Complications

Anastomosis leaks or staple line leaks Pulmonary Embolism or DVT Cholelithiasis Stomal ulceration Dumping syndrome Constipation

Anastamosis Leaks

Up to 7-10 days after surgery Most common at gastrojejunostomy enteroenterostomy Roux

limb stump staple line Can lead to peritonitis sepsis possible death Presentation

Tachycardia tachypnea Fever Ab painback pain Pelvic pressure or rebound tenderness

Anastamosis Leaks

Order Gastrograffin upper GI series Subclinical cases

Bowel rest Parenteral nutrition IV antibiotic if H pylori

Clinically suspect leak Laparoscopic evaluation and leak repair

Failure to evaluate is the most common cause of preventable major long-term disability or death in bariatric surgical patients

Pulmonary Embolism

Sudden cause of death up to one month after surgery 20-30 mortality rate High risk may have vena cava filter placement prior to surgery Prophylaxis with compression stockings and LMWH Early ambulation imperitive

Pulmonary Embolism

Presentation Profound hypoxia Hypotension Signs of sepsis

Immediate spiral chest CT Abdominal exploration if too large for machine No pathology start anticoagulation Too largehelliphellipNO SURGERY

Cholelithiasis

Up to 36 of patients within 6 months post-op Bile stasis leads to increased sludge and gallstones Prophylactic cholecystectomy prior to surgery if

evidence of existing sludge or stones Prevent post-operative disease with concurrent bariatric

surgery and cholecystectomy Prophylactic use of urosidol

Expensive and unpalatable

Stomal Ulceration

12-15 within 2-4 mos Post-surgery Etiology

Overabundant acid in pouch leads to excessive acid passing through stoma

Pouch tension and staple line breakdown NSAID use

Presentation Dyspepsia vomiting Epigastric or retrosternal pain

Stomal Ulceration

Treatment PPI carafate Antibiotics if H Pylori Avoid NSAIDS alcohol smoking

If no response to treatment Endoscopy Back to surgery for pouch revision or staple line repair

Dumping Syndrome

More than 15 patients Hypotention Tachycardia Lightheadedness syncope Flushing Abdominal cramping and diarrhea Nausea and vomiting

Dumping Syndrome

Occurs with high dose simple sugar ingestion Sugar in small intestine causes osmotic overload and fluid

shift from blood to intestine Increased intestinal volume leads to watery diarrhea Decreased blood volume leads to systemic changes Patient education

Eat slowly Avoid drinking before during and not until 30 minutes after meals

Constipation

Most common complaint Causes

Dehydration and decreased fluid intake post-operatively Increased metabolic water needs Calcium and iron supplement use following surgery

Treat with increased fluids and stool softeners

Nutritional Consequences

Iron deficiency anemia B12 deficiency Folate deficiency Calcium and Vitamin D deficiency

Not seen with purely restrictive surgeries

Iron deficiency and anemia

Common following RYGB As high as 49 of patients Multifactorial cause

Low gastric acid levels prohibit iron cleavage from food Absorption inhibited because no nutrient exposure to duodenum or

proximal jejunum Decrease in iron-rich food consumption due to intolerance

Treat with oral supplementation of ferrous sulfate or ferrous gluconate

Vitamin B12 deficiency

Up to 70 of patients Lack of hydrochloric acid and pepsin in stomach

Prevents B12 cleavage from food Affects secretion of intrinsic factor thus B12 absorption

Intolerance to meat and milk Oral supplementation usually adequate otherwise IM injections used

Folate Deficiency

40 of gastric bypass patients Complete absorption requires B12 Absorption dependent on HCl and upper 13 stomach Deficiency generally caused by decreased consumption Oral supplementation

Vitamin D and Calcium Deficiency

Vitamin D deficiency is common among obese people Calcium absorption decreased because duodenum is

bypassed Intolerance to dairy foods high in calcium Vitamin D is required for Ca++ absorption Prolonged deficiencies lead to

Bone resorption osteomalacia osteoporosis Treat with calcium citrate supplementation and 2 weekly

doses of Vitamin D

Nutritional Implications of Various Bariatric Surgeries(34)

bull RYGB Malabsorption of Vit B12 Vit B1 (thiamin) Vit D Vit K Folate Iron Calcium

bull LAGB Folic Acid deficiency

bull BPD and BPDDS Vit A D E and K deficiency Protein-Calorie Malnutrition Malabsorption of

Calcium Zinc Selenium Sodium Potassium Chloride Phosphorus Magnesium

Recommended Daily Supplements(4)

Multivitamin with iron (prenatal vitamin will have adeq amount of folic acid)

Calcium (citrate) with vitamin D (1200-1500 mg calcium with 800-1000 IU vitamin D)

Oral vitamin B12 (500-1000 mcg) Iron (65 mgday in elemental form)

Vitamin C (to increase absorption of Iron) Thiamin (10 mgday)

Diet Recommendations(3)

Reduce food volume Chew food very well Slow pace of eating No liquids with meals Encourage fruits and vegetables as diet progresses Include high protein foods (at least 60gday) may need protein

supplements

Diet Progression Gastric Bypass

Stage 1 Clear liquids and protein supplement (1 week)

Stage 2No concentrated sweets low fat puree diet ( 3 weeks)

Stage 3 Regular texture weight reduction diet

Diet Progression Lap - Band

Stage 1 Clear liquids and protein supplement ( 2 weeks)

Stage 2 No concentrated sweets low fat puree diet (2weeks)

Stage 3 Regular texture weight reduction diet

Stage 1

Only clear liquids allowed Avoid sweetened beverages Sip very slowly No straws Avoid caffeinated carbonated and alcoholic beverages STOP drinking if you feel fullness pain or discomfort

Protein supplements

Begin the day after you go home from Hospital

Minimum protein target 70gmsday

May use powder or pre-mixed liquid forms (Whey protein is preferred)

Protein pills may not be used

Vitamin and Mineral Supplements

Gastric bypass patients In addition to eating much less food gastric bypass patients will also

absorb vitamins and minerals differently after surgery They will require daily multivitamin calcium and iron

supplementation for the rest of your life

Vitamin and Mineral Supplements

Lap-Bandreg patients

Require a multivitamin with minerals daily

It may be necessary to take additional vitamins and minerals eg calcium iron folateB1 B12These will be prescribed as needed

Stage 2 dietPUREE

Puree diet

Regular scheduled meals Avoid meal skipping Plan meals in advance Eat Slowly Eat protein foods first Moisten meats Use liquid protein as supplement not as meal replacement

Measure 2 oz portions at each meal eating when full Separate liquids and solids No bread rice or pasta Avoid added sugars and high fat

foods VARIETY

Contraindications

Factors that may be considered contraindications include unstable CAD uncontrolled severe OSA uncontrolled psychiatric disorder mental retardation (IQ lt 60) inability to understand the surgery perceived inability to adhere to postoperative restrictions continued drug abuse malignancy with a poor 5-year survival prognosis Cirrhotic liver disease with portal hypertension

Preoperative EvaluationAttention should focus on issues unique to the obese patient

particularly cardiorespiratory status and the airwayConsideration of co morbidities ie hypertension diabetes heart

failure IHD obesity-hypoventilation syndrome metabolic syndrome etc

Results of the sleep study History of previous surgeries their anesthetic challenges need for

ICU admissionCurrent medicationsPatients scheduled for repeat bariatric surgery should be screened

preoperatively for long-term metabolic and nutritional abnormalities

Investigationshellip Recommended preoperative laboratory evaluations include

fasting blood glucose lipid profile electrolytes serum chemistries (to evaluate renal and hepatic function) complete blood count Serum ferritin vitamin B12 thyrotropin amp 25-hydroxyvitamin D

(Miller 7th edition- anesthesia for Bariatic Surgery) ABG measurements help evaluate ventilation as well as the need for perioperative oxygen administration and

postoperative ventilation Routine pulmonary function tests and liver function tests are not cost-effective in asymptomatic obese patients Coaugulation profile ( liver problem repeat surgery orlistat) ECG echocardiography Sleep study if suspected OSA

(Barash 6th edition anesthesia and obesity)

Concurrent Preoperative and Prophylactic Medications

Patients usual medications should be continued until the time of surgery with the possible exception of insulin and oral hypoglycemics

Antibiotic prophylaxis is usually indicated

Obesity itself does not increase the risk for aspiration acid aspiration prophylaxis including H2 receptor agonists or proton pump inhibitors must be considered in patients with identifiable risk for aspiration

Anxiolysis and prophylaxis against deep vein thrombosis (DVT) should be addressed at premedication

DVT consideration Morbid obesity is a major independent risk factor for sudden death from

acute postoperative pulmonary embolism Subcutaneous heparin 5000 IU administered before surgery and repeated every 8 to 12

hours until the patient is fully mobile reduces the risk of DVT LMWH can also be used

Preoperative prophylactic placement of an inferior vena cava filter should be considered in venous stasis disease BMI ge60 truncal obesity and OSA

What Are the Risks

MAJOR RISKS Death (1 of patients die within 30 days) Severe malnutrition (anemia PEM osteomalacia) Peritonitis (from leakage or ruptures at staple sites)

or other infection Obstructions caused by scar tissue in the stomach or

bowels

MINOR RISKS Dumping Syndrome (unpleasant but not harmful) Diarrhea and malodorous gas production Lactose intolerance Hair loss (short-term post-surgery) May have to eventually undergo surgical revision Pain post-surgery

History of Bariatric Surgery

Obesity surgery is not a new discipline The earliest Bariatric procedure performed was in 1954 at Minnesota The procedure

was Jejuno-ileal bypass In 1966Gastric Bypass was introduced as a surgical procedure for weight loss at the

University of Iowa In 1977Griffen reported the first Roux-en-Y Gastric Bypass In 1980surgeons with a more conservative approach developed the Vertical Banded

Gastroplasty Other procedures with longer intestinal segment bypass were also introduced such as

Biliopancreatic Diversions These complex procedures are recommended in super-obese patients ie BMIgt60

How does surgery work

RESTRICTIVE - RESTRICT AMOUNT OF FOOD INGESTED Decreases appetitehunger

Early satiety Behavior modification Gastric Banding (Lap Band)

Roux-en Y Gastric bypass (RYGB) Sleeve Gastrectomy

MALABSORPTIVE- LIMITS DIGESTION AND ABSORPTION Decreases length of intestine exposed to digested food

25 of fat is absorbed Behavior modification

Biliopancreatic Diversion Duodenal Switch (BPDDS)

ALL OPERATIONS CAN BE PERFORMED OPEN OR LAPAROSCOPICALLY

Laparoscopic vs Open

OPEN uarr post op pain Longer hospitalizations uarr wound complications

Infection Hernias Seromas

Return to work in 4-8 weeks

LAPAROSCOPIC darr post op pain Early mobility darr Wound complications 2-3 day hospital stay Return to work in 1-3 weeks

1 Nguyen NT et al Accelerated growth of bariatric surgery with the introduction of minimally invasive surgery Arch Surg 20051401198-202

Procedures that are solely restrictive by creating a small gastric pouch of volume 15 to 30 cc amp a degree of outlet obstruction leading to delayed gastric emptying The goal is to reduce oral intake by limiting gastric volume produce early satiety and leave the alimentary canal in continuity minimizing the risks of metabolic complications

1VERTICAL BANDED GASTROPLASTY

2ADJUSTABLE GASTRIC BANDING (LAGB )

3 SLEEVE GASTRECTOMY

4GASTRIC PLICATION

5 INTRA GASTRIC BALLOON (GASTRIC BALLOON)

RESTRICTIVE PROCEDURES

Malabsorption is achieved by creating a short gut syndrome andor by accomplishing distal mixing of bile and pancreatic juice with ingested nutrients thereby reducing absorption Some purely malabsorptive operations are no longer recommended due to their potential hazard to cause serious nutritional deficiencies

1 BILIOPANCREATIC DIVERSION2 THE JEJUNAL-ILEAL BYPASS3 ENDOLUMINAL SLEEVE

MALABSORPTIVE PROCEDURES

MIXED PROCEDURES

1GASTRIC BYPASS ROUX-EN-Y ( RYGBP)

2SLEEVE GASTRECTOMY WITH DUODENAL SWITCH

3IMPLANTABLE 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

The stomach is partitioned along its axis with a non-

adjustable poly-urethane band and with linear amp 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 was practiced in 1980

Vertical Banded Gastroplasty (VBG)

ADJUSTABLE GASTRIC BANDING (LAP BAND SURGERY LAGB)

Restrictive Procedure The procedure was first performed by Cadiere in 1992 but was made popular by Belachew and Legrand in 1993 An inflatable silicone BAND is placed around the top portion of the stomach to form a small stomach pouch amp sewed

This band is connected to a tube that leads to a port above the abdominal muscles placed below the skin (FILL ndash PORT)

During follow up visits we inject or remove saline solution to make the band tighter or looser

Adjustable Gastric Band

bull 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

How does the Band work

Surgery Factors Restriction of meal size Decreased appetite

Patient Factors Decreased calorie intake Increased calorie expenditure

LAP-BAND Adjustability

Unfilled Band Filled Band

Adjustments are made in the office

Complications of Gastric Lap-Band

bull Perforation of Stomachbull Slippagebull Gastric Erosion(much less after Pars flaccida technique) bull Dilated Esophagusbull Tubing access port problemsbull Mal positioningbull Abdominal Painbull Heartburnbull Vomitingbull Inability to Adjust the Bandbull Failure to Lose Weightbull Infection of Systembull Fatigue or malfunction

Advantages

No intestinal surgery No staplingcutting of stomach No nutritional risks Adjustable Reversible Safe

Foreign body Frequent follow-up visits Needs more commitment Easy to cheat

Disadvantages

Comparison of Adjustable Gastric Banding and Vertical Banded Gastroplasty

Laparoscopic adjustable gastric banding Reversible Adjustable Simpler to perform laparoscopically Sustained weight loss of gt50 EBW gt5

years following surgery Complications Gastric prolapse band

erosion rarely gastric perforation and access port complications

Vertical banded gastroplasty Irreversible Non adjustable Technically difficult by laparoscopy Weight loss of 25-50 EBW and weight gain

after 2-3 years Complications suture line disruption gastric

leak weight gain

>

>

Originally used as the first-stage operation for a proposed biliopancreatic diversion with duodenal switch in high-risk patients

The sleeve gastrectomy has caught on as a primary obesity treatment as surgeons are reporting weight loss of 55 of excess body weight past 5 years in some patients

The sleeve gastrectomy is also known as the greater curvature gastrectomy vertical or longitudinal gastrectomy or Pylorus preserving lsquogastric tube creationrsquo

Rapid and less traumatic operation Good resolution of co-morbidities and good weight loss

A further second surgical step is then easily feasible if necessary

SLEEVE GASTRECTOMY

SLEEVE GASTRECTOMY

A sleeve gastrectomy involves resection of

approximately 80 of the greater curvature

side of the stomach

Smaller tubular gastric ldquosleeverdquo created

along the lesser curve that is based on the

lesser curvature blood supply

Ideal approximate capacity of the stomach

after the procedure is about 30- 60 ml pouch

1MECHANICAL RESTRICTION by reducing the volume of the stomach and impairing stomach mobility Also called lsquoFood limitingrsquo operation

2HORMONAL MODIFICATION by removing a great part of the Ghrelin (Hunger Hormone) production tissue

(Ghrelin is a 28 amino-acid-peptide secreted by the oxyntic glands of the gastric fungus It is a potent orexigenic (appetite-stimulating) peptide mediated by the activation of its receptors in the hypothalamus or pituitary area)

The gastric fundus contains 10 to 20 times more ghrelin per one gram of tissue than the duodenum In the SG resection of the fundus removes the major portion of ghrelin release therefore appetite decreases

The sleeve gastrectomy (SG) induces weight loss by 2 mechanisms

>

Intragastric balloon involves placing a deflated balloon into the stomach and then filling it to decrease the amount of gastric space

The balloon can be left in the stomach for a maximum of 6 months and results in an average weight loss of 5ndash9 BMI over half a year

Done endoscopically

The intragastric balloon may be used prior to another bariatric surgery as a step-down procedure

INTRA GASTRIC BALLOON

>

>

The EndoBarrier gastrointestinal liner mimics the effects of gastric bypass surgery

Itrsquos designed to work by inserting a flexible

tube-like barrier into the duodenum amp 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

ENDO BARRIER LINER SYSTEM

B MAL- ABSORPTIVE PROCEDURES

Malabsorptive surgeries rearrange andor remove part of digestive system which then limits the amount of calories and nutrients that body can absorb Treatment with a large malabsorptive component results in the most weight loss but tend to have slightly higher complication rates

1JEJUNAL ILEAL BYPASS ndash no longer performed for high complication rates

2ILEAL TRANSPOSITION- New malabsoptive procedure on trial for treatment of DM type 2 and metabolic disorders

C COMBINATION PROCEDURES RESTRICTIVE + MALABSORBTIVE

1LAP GASTRIC BYPASS ndash ROUX-EN- Y ndash more malabsorption than the restrictive

2MINI- GASTRIC BYPASS- mainly restrictive

3DUODENAL SWITCH ndash the sleeve stomach is the restrictive portion ampthe intestinal bypass (duodenal switch) is the malabsorptive component

When surgery combines both restrictive and malabsorptive techniques it is know as a ldquocombinationrdquo procedure Most types of bariatric surgery carry at least a small element of both components but the following surgeries achieve a notable portion of weight loss from eachhellip

1 LAP GASTRIC BYPASS LGB

The Roux-en-Y gastric bypass(known simply as the LRYGBP) is the most commonly performed procedure

It primarily causesweight loss by restricting thefood intake however there ismore amount of mal absorption that occurs with this operation

GASTRIC BYPASS LRYGBP

bullThe stomach is stapled into2 pieces one small and one large The small piece becomes the ldquonewrdquo stomach pouch

bull The larger portion of the stomach stays in place however will lie dormant for the remainder of the patientrsquos life

GASTRIC BYPASS LGB

bull The small intestine (the jejunum) is divided using a surgical staplerApprox 50-70 cm from the DJ Junction

GASTRIC BYPASS LGB

Y- LIMB BP LIMB

bull The end of the Roux limb is then attached to the newly formed stomach pouch which carries food to the distal intestine

bull The Roux loop is completed by forming a jejunostomy

bull The Y limb or BPD limb carries digestive juices from the pancreas gall bladder liver and duodenum to the intestines

bull The food and the digestive juices mix where the Roux limb and Y limb meet much below say 100-150 cm from DJ

Roux limb or alimentary limb

100-150 cm

How Does the Roux-en-Y Work

Surgery factors restriction of meal size ldquodumping syndromerdquo some malabsorption decreased appetite

Patient factors calorie intake calorie expenditure

bull Most commonly performedbull Most reliable operation for long term weight lossbull Long term weight loss averages 60 to 75 percent of EBWbull Malnutrition is unusualbull Substantial improvement amp resolution in many co-morbid

obesity conditions

ADVANTAGES OF RYGBP

1 Not reversible

2 Mortality 05- 1

3 Perioperative complications 5-10

4 Stricture of gastrojejunostomy-10 (long term)

5 Long term risk of protein amp vitamin deficiency and marginal ulceration of GJA

6Long term risk of intestinal obstruction ndash 2

LAPAROSCOPIC GASTRIC BYPASSCOMPLICATIONS

Biliopancreatic Diversion (BPD)

Primarily malabsorptive but restrictive component also

First Terminal ileum is measured to a length of 50 cms marked with suture

The alimentary tract beyond the proximal part of stomach is rearranged to

include only distal 200 cm of ileum including common channel

Common channel-Distal 50 cm of terminal ileum for absorption of fat and

protein

The proximal end of ileum anastomosed to proximal end of stomach after

performing distal hemigastrectomy

Biliopancreatic Diversion with Duodenal Switch

Modification to lessen high incidence of vit b12 deficiency anastomotic stricture at gastrojejunal anastomosis

This procedure involves a sleeve gastrectomy that is then diverted at the duodenum into the ileum at a point measured proximally from the ileocecal valve (usually 250 cm)

The distal duodenum and jejunum the biliopancreatic limb are then anastomosed to the ileum at a point measured proximally from the ileocecal valve (usually 100 cm)

Common channel is 100cm Entire alimentary tract is 250 cm This is the most aggressive bypass procedure commonly offered today Major difference-Sleeve gastrectomy instead of distal hemigastrectomy

bull Most women regained normal menstrual function and most had documented

spontaneous ovulation

bull Significant improvement in hirsutism androgen profiles and about a 50 reduction in

HOMA-IR

bull Follow up for more than 2 years showed that all women resumed normal menstrual

cycles HbA1C decreased from 82 to 51 in lt 3 months

bull 78 saw improvement in metabolic syndrome amp 48 showed improvement in PCOS

2 ROLE OF BARIATRIC SURGERY IN PCOS PATIENTS

bull Decrease menstrual irregularities bull PCOS women have less hyper androgenism

bull Sex hormone binding globulin increases bull LH and FSH levels have been reported to increase

bull Ovulatory function measured by luteal LH and Progesterone secretion improved bull Leptin levels decrease reflecting improved reproductive metabolic status

bull Subclinical hypothyroidism significantly reduced

THE SAFE TIMING OF PREGNANCYoptimal or minimal time gt12 months after bariatric surgery before becoming pregnant in order to allow the rapid weight loss and metabolic changes to subside

4 BARIATRIC SURGERY IN REPRODUCTIVE WOMEN

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)

The foregut hypothesis theory ndash 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

Effect of Bariatric Surgery on Diabetes Mellitus

Combined Gastric Restriction amp Malabsorption

Operative Risks (vs cholecystectomy)

Perioperative Mortality 1-2 vs 02-08 Early Complications 10 vs 29Late Complications 20 vs 1-2

LimitationsWidening of (unbanded) gastrojejunostomyExpansion of gastric pouch 25 with nearly 100 weight regainAdaptation of limb that receives the food

SUMMARY OF ALL TYPES OF SURGERY

bull LRYGBP ndash worlds best procedure 60-70 WL dumping syndrome malnutrition

bull LAGB- low complications varying range of wt loss frequent post-op visits ( 10)

bull DSBPD- more wt loss high complications good for high BMI gt 50 malabsorption +

bull VBG(vertical band gastroplasty) ndash longest available results good wt loss improved co-morbidities right for some ptsrisks too high to justify rewards

bull SG- needs long term research 1st step procedure low risks higher wt loss lesser complications pouch could Stretch over time long staple line could cause problems in future frequency is accelerating because of technical ease 1st stage procedure before bypass

Post-surgical Complications

Anastomosis leaks or staple line leaks Pulmonary Embolism or DVT Cholelithiasis Stomal ulceration Dumping syndrome Constipation

Anastamosis Leaks

Up to 7-10 days after surgery Most common at gastrojejunostomy enteroenterostomy Roux

limb stump staple line Can lead to peritonitis sepsis possible death Presentation

Tachycardia tachypnea Fever Ab painback pain Pelvic pressure or rebound tenderness

Anastamosis Leaks

Order Gastrograffin upper GI series Subclinical cases

Bowel rest Parenteral nutrition IV antibiotic if H pylori

Clinically suspect leak Laparoscopic evaluation and leak repair

Failure to evaluate is the most common cause of preventable major long-term disability or death in bariatric surgical patients

Pulmonary Embolism

Sudden cause of death up to one month after surgery 20-30 mortality rate High risk may have vena cava filter placement prior to surgery Prophylaxis with compression stockings and LMWH Early ambulation imperitive

Pulmonary Embolism

Presentation Profound hypoxia Hypotension Signs of sepsis

Immediate spiral chest CT Abdominal exploration if too large for machine No pathology start anticoagulation Too largehelliphellipNO SURGERY

Cholelithiasis

Up to 36 of patients within 6 months post-op Bile stasis leads to increased sludge and gallstones Prophylactic cholecystectomy prior to surgery if

evidence of existing sludge or stones Prevent post-operative disease with concurrent bariatric

surgery and cholecystectomy Prophylactic use of urosidol

Expensive and unpalatable

Stomal Ulceration

12-15 within 2-4 mos Post-surgery Etiology

Overabundant acid in pouch leads to excessive acid passing through stoma

Pouch tension and staple line breakdown NSAID use

Presentation Dyspepsia vomiting Epigastric or retrosternal pain

Stomal Ulceration

Treatment PPI carafate Antibiotics if H Pylori Avoid NSAIDS alcohol smoking

If no response to treatment Endoscopy Back to surgery for pouch revision or staple line repair

Dumping Syndrome

More than 15 patients Hypotention Tachycardia Lightheadedness syncope Flushing Abdominal cramping and diarrhea Nausea and vomiting

Dumping Syndrome

Occurs with high dose simple sugar ingestion Sugar in small intestine causes osmotic overload and fluid

shift from blood to intestine Increased intestinal volume leads to watery diarrhea Decreased blood volume leads to systemic changes Patient education

Eat slowly Avoid drinking before during and not until 30 minutes after meals

Constipation

Most common complaint Causes

Dehydration and decreased fluid intake post-operatively Increased metabolic water needs Calcium and iron supplement use following surgery

Treat with increased fluids and stool softeners

Nutritional Consequences

Iron deficiency anemia B12 deficiency Folate deficiency Calcium and Vitamin D deficiency

Not seen with purely restrictive surgeries

Iron deficiency and anemia

Common following RYGB As high as 49 of patients Multifactorial cause

Low gastric acid levels prohibit iron cleavage from food Absorption inhibited because no nutrient exposure to duodenum or

proximal jejunum Decrease in iron-rich food consumption due to intolerance

Treat with oral supplementation of ferrous sulfate or ferrous gluconate

Vitamin B12 deficiency

Up to 70 of patients Lack of hydrochloric acid and pepsin in stomach

Prevents B12 cleavage from food Affects secretion of intrinsic factor thus B12 absorption

Intolerance to meat and milk Oral supplementation usually adequate otherwise IM injections used

Folate Deficiency

40 of gastric bypass patients Complete absorption requires B12 Absorption dependent on HCl and upper 13 stomach Deficiency generally caused by decreased consumption Oral supplementation

Vitamin D and Calcium Deficiency

Vitamin D deficiency is common among obese people Calcium absorption decreased because duodenum is

bypassed Intolerance to dairy foods high in calcium Vitamin D is required for Ca++ absorption Prolonged deficiencies lead to

Bone resorption osteomalacia osteoporosis Treat with calcium citrate supplementation and 2 weekly

doses of Vitamin D

Nutritional Implications of Various Bariatric Surgeries(34)

bull RYGB Malabsorption of Vit B12 Vit B1 (thiamin) Vit D Vit K Folate Iron Calcium

bull LAGB Folic Acid deficiency

bull BPD and BPDDS Vit A D E and K deficiency Protein-Calorie Malnutrition Malabsorption of

Calcium Zinc Selenium Sodium Potassium Chloride Phosphorus Magnesium

Recommended Daily Supplements(4)

Multivitamin with iron (prenatal vitamin will have adeq amount of folic acid)

Calcium (citrate) with vitamin D (1200-1500 mg calcium with 800-1000 IU vitamin D)

Oral vitamin B12 (500-1000 mcg) Iron (65 mgday in elemental form)

Vitamin C (to increase absorption of Iron) Thiamin (10 mgday)

Diet Recommendations(3)

Reduce food volume Chew food very well Slow pace of eating No liquids with meals Encourage fruits and vegetables as diet progresses Include high protein foods (at least 60gday) may need protein

supplements

Diet Progression Gastric Bypass

Stage 1 Clear liquids and protein supplement (1 week)

Stage 2No concentrated sweets low fat puree diet ( 3 weeks)

Stage 3 Regular texture weight reduction diet

Diet Progression Lap - Band

Stage 1 Clear liquids and protein supplement ( 2 weeks)

Stage 2 No concentrated sweets low fat puree diet (2weeks)

Stage 3 Regular texture weight reduction diet

Stage 1

Only clear liquids allowed Avoid sweetened beverages Sip very slowly No straws Avoid caffeinated carbonated and alcoholic beverages STOP drinking if you feel fullness pain or discomfort

Protein supplements

Begin the day after you go home from Hospital

Minimum protein target 70gmsday

May use powder or pre-mixed liquid forms (Whey protein is preferred)

Protein pills may not be used

Vitamin and Mineral Supplements

Gastric bypass patients In addition to eating much less food gastric bypass patients will also

absorb vitamins and minerals differently after surgery They will require daily multivitamin calcium and iron

supplementation for the rest of your life

Vitamin and Mineral Supplements

Lap-Bandreg patients

Require a multivitamin with minerals daily

It may be necessary to take additional vitamins and minerals eg calcium iron folateB1 B12These will be prescribed as needed

Stage 2 dietPUREE

Puree diet

Regular scheduled meals Avoid meal skipping Plan meals in advance Eat Slowly Eat protein foods first Moisten meats Use liquid protein as supplement not as meal replacement

Measure 2 oz portions at each meal eating when full Separate liquids and solids No bread rice or pasta Avoid added sugars and high fat

foods VARIETY

Preoperative EvaluationAttention should focus on issues unique to the obese patient

particularly cardiorespiratory status and the airwayConsideration of co morbidities ie hypertension diabetes heart

failure IHD obesity-hypoventilation syndrome metabolic syndrome etc

Results of the sleep study History of previous surgeries their anesthetic challenges need for

ICU admissionCurrent medicationsPatients scheduled for repeat bariatric surgery should be screened

preoperatively for long-term metabolic and nutritional abnormalities

Investigationshellip Recommended preoperative laboratory evaluations include

fasting blood glucose lipid profile electrolytes serum chemistries (to evaluate renal and hepatic function) complete blood count Serum ferritin vitamin B12 thyrotropin amp 25-hydroxyvitamin D

(Miller 7th edition- anesthesia for Bariatic Surgery) ABG measurements help evaluate ventilation as well as the need for perioperative oxygen administration and

postoperative ventilation Routine pulmonary function tests and liver function tests are not cost-effective in asymptomatic obese patients Coaugulation profile ( liver problem repeat surgery orlistat) ECG echocardiography Sleep study if suspected OSA

(Barash 6th edition anesthesia and obesity)

Concurrent Preoperative and Prophylactic Medications

Patients usual medications should be continued until the time of surgery with the possible exception of insulin and oral hypoglycemics

Antibiotic prophylaxis is usually indicated

Obesity itself does not increase the risk for aspiration acid aspiration prophylaxis including H2 receptor agonists or proton pump inhibitors must be considered in patients with identifiable risk for aspiration

Anxiolysis and prophylaxis against deep vein thrombosis (DVT) should be addressed at premedication

DVT consideration Morbid obesity is a major independent risk factor for sudden death from

acute postoperative pulmonary embolism Subcutaneous heparin 5000 IU administered before surgery and repeated every 8 to 12

hours until the patient is fully mobile reduces the risk of DVT LMWH can also be used

Preoperative prophylactic placement of an inferior vena cava filter should be considered in venous stasis disease BMI ge60 truncal obesity and OSA

What Are the Risks

MAJOR RISKS Death (1 of patients die within 30 days) Severe malnutrition (anemia PEM osteomalacia) Peritonitis (from leakage or ruptures at staple sites)

or other infection Obstructions caused by scar tissue in the stomach or

bowels

MINOR RISKS Dumping Syndrome (unpleasant but not harmful) Diarrhea and malodorous gas production Lactose intolerance Hair loss (short-term post-surgery) May have to eventually undergo surgical revision Pain post-surgery

History of Bariatric Surgery

Obesity surgery is not a new discipline The earliest Bariatric procedure performed was in 1954 at Minnesota The procedure

was Jejuno-ileal bypass In 1966Gastric Bypass was introduced as a surgical procedure for weight loss at the

University of Iowa In 1977Griffen reported the first Roux-en-Y Gastric Bypass In 1980surgeons with a more conservative approach developed the Vertical Banded

Gastroplasty Other procedures with longer intestinal segment bypass were also introduced such as

Biliopancreatic Diversions These complex procedures are recommended in super-obese patients ie BMIgt60

How does surgery work

RESTRICTIVE - RESTRICT AMOUNT OF FOOD INGESTED Decreases appetitehunger

Early satiety Behavior modification Gastric Banding (Lap Band)

Roux-en Y Gastric bypass (RYGB) Sleeve Gastrectomy

MALABSORPTIVE- LIMITS DIGESTION AND ABSORPTION Decreases length of intestine exposed to digested food

25 of fat is absorbed Behavior modification

Biliopancreatic Diversion Duodenal Switch (BPDDS)

ALL OPERATIONS CAN BE PERFORMED OPEN OR LAPAROSCOPICALLY

Laparoscopic vs Open

OPEN uarr post op pain Longer hospitalizations uarr wound complications

Infection Hernias Seromas

Return to work in 4-8 weeks

LAPAROSCOPIC darr post op pain Early mobility darr Wound complications 2-3 day hospital stay Return to work in 1-3 weeks

1 Nguyen NT et al Accelerated growth of bariatric surgery with the introduction of minimally invasive surgery Arch Surg 20051401198-202

Procedures that are solely restrictive by creating a small gastric pouch of volume 15 to 30 cc amp a degree of outlet obstruction leading to delayed gastric emptying The goal is to reduce oral intake by limiting gastric volume produce early satiety and leave the alimentary canal in continuity minimizing the risks of metabolic complications

1VERTICAL BANDED GASTROPLASTY

2ADJUSTABLE GASTRIC BANDING (LAGB )

3 SLEEVE GASTRECTOMY

4GASTRIC PLICATION

5 INTRA GASTRIC BALLOON (GASTRIC BALLOON)

RESTRICTIVE PROCEDURES

Malabsorption is achieved by creating a short gut syndrome andor by accomplishing distal mixing of bile and pancreatic juice with ingested nutrients thereby reducing absorption Some purely malabsorptive operations are no longer recommended due to their potential hazard to cause serious nutritional deficiencies

1 BILIOPANCREATIC DIVERSION2 THE JEJUNAL-ILEAL BYPASS3 ENDOLUMINAL SLEEVE

MALABSORPTIVE PROCEDURES

MIXED PROCEDURES

1GASTRIC BYPASS ROUX-EN-Y ( RYGBP)

2SLEEVE GASTRECTOMY WITH DUODENAL SWITCH

3IMPLANTABLE 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

The stomach is partitioned along its axis with a non-

adjustable poly-urethane band and with linear amp 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 was practiced in 1980

Vertical Banded Gastroplasty (VBG)

ADJUSTABLE GASTRIC BANDING (LAP BAND SURGERY LAGB)

Restrictive Procedure The procedure was first performed by Cadiere in 1992 but was made popular by Belachew and Legrand in 1993 An inflatable silicone BAND is placed around the top portion of the stomach to form a small stomach pouch amp sewed

This band is connected to a tube that leads to a port above the abdominal muscles placed below the skin (FILL ndash PORT)

During follow up visits we inject or remove saline solution to make the band tighter or looser

Adjustable Gastric Band

bull 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

How does the Band work

Surgery Factors Restriction of meal size Decreased appetite

Patient Factors Decreased calorie intake Increased calorie expenditure

LAP-BAND Adjustability

Unfilled Band Filled Band

Adjustments are made in the office

Complications of Gastric Lap-Band

bull Perforation of Stomachbull Slippagebull Gastric Erosion(much less after Pars flaccida technique) bull Dilated Esophagusbull Tubing access port problemsbull Mal positioningbull Abdominal Painbull Heartburnbull Vomitingbull Inability to Adjust the Bandbull Failure to Lose Weightbull Infection of Systembull Fatigue or malfunction

Advantages

No intestinal surgery No staplingcutting of stomach No nutritional risks Adjustable Reversible Safe

Foreign body Frequent follow-up visits Needs more commitment Easy to cheat

Disadvantages

Comparison of Adjustable Gastric Banding and Vertical Banded Gastroplasty

Laparoscopic adjustable gastric banding Reversible Adjustable Simpler to perform laparoscopically Sustained weight loss of gt50 EBW gt5

years following surgery Complications Gastric prolapse band

erosion rarely gastric perforation and access port complications

Vertical banded gastroplasty Irreversible Non adjustable Technically difficult by laparoscopy Weight loss of 25-50 EBW and weight gain

after 2-3 years Complications suture line disruption gastric

leak weight gain

>

>

Originally used as the first-stage operation for a proposed biliopancreatic diversion with duodenal switch in high-risk patients

The sleeve gastrectomy has caught on as a primary obesity treatment as surgeons are reporting weight loss of 55 of excess body weight past 5 years in some patients

The sleeve gastrectomy is also known as the greater curvature gastrectomy vertical or longitudinal gastrectomy or Pylorus preserving lsquogastric tube creationrsquo

Rapid and less traumatic operation Good resolution of co-morbidities and good weight loss

A further second surgical step is then easily feasible if necessary

SLEEVE GASTRECTOMY

SLEEVE GASTRECTOMY

A sleeve gastrectomy involves resection of

approximately 80 of the greater curvature

side of the stomach

Smaller tubular gastric ldquosleeverdquo created

along the lesser curve that is based on the

lesser curvature blood supply

Ideal approximate capacity of the stomach

after the procedure is about 30- 60 ml pouch

1MECHANICAL RESTRICTION by reducing the volume of the stomach and impairing stomach mobility Also called lsquoFood limitingrsquo operation

2HORMONAL MODIFICATION by removing a great part of the Ghrelin (Hunger Hormone) production tissue

(Ghrelin is a 28 amino-acid-peptide secreted by the oxyntic glands of the gastric fungus It is a potent orexigenic (appetite-stimulating) peptide mediated by the activation of its receptors in the hypothalamus or pituitary area)

The gastric fundus contains 10 to 20 times more ghrelin per one gram of tissue than the duodenum In the SG resection of the fundus removes the major portion of ghrelin release therefore appetite decreases

The sleeve gastrectomy (SG) induces weight loss by 2 mechanisms

>

Intragastric balloon involves placing a deflated balloon into the stomach and then filling it to decrease the amount of gastric space

The balloon can be left in the stomach for a maximum of 6 months and results in an average weight loss of 5ndash9 BMI over half a year

Done endoscopically

The intragastric balloon may be used prior to another bariatric surgery as a step-down procedure

INTRA GASTRIC BALLOON

>

>

The EndoBarrier gastrointestinal liner mimics the effects of gastric bypass surgery

Itrsquos designed to work by inserting a flexible

tube-like barrier into the duodenum amp 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

ENDO BARRIER LINER SYSTEM

B MAL- ABSORPTIVE PROCEDURES

Malabsorptive surgeries rearrange andor remove part of digestive system which then limits the amount of calories and nutrients that body can absorb Treatment with a large malabsorptive component results in the most weight loss but tend to have slightly higher complication rates

1JEJUNAL ILEAL BYPASS ndash no longer performed for high complication rates

2ILEAL TRANSPOSITION- New malabsoptive procedure on trial for treatment of DM type 2 and metabolic disorders

C COMBINATION PROCEDURES RESTRICTIVE + MALABSORBTIVE

1LAP GASTRIC BYPASS ndash ROUX-EN- Y ndash more malabsorption than the restrictive

2MINI- GASTRIC BYPASS- mainly restrictive

3DUODENAL SWITCH ndash the sleeve stomach is the restrictive portion ampthe intestinal bypass (duodenal switch) is the malabsorptive component

When surgery combines both restrictive and malabsorptive techniques it is know as a ldquocombinationrdquo procedure Most types of bariatric surgery carry at least a small element of both components but the following surgeries achieve a notable portion of weight loss from eachhellip

1 LAP GASTRIC BYPASS LGB

The Roux-en-Y gastric bypass(known simply as the LRYGBP) is the most commonly performed procedure

It primarily causesweight loss by restricting thefood intake however there ismore amount of mal absorption that occurs with this operation

GASTRIC BYPASS LRYGBP

bullThe stomach is stapled into2 pieces one small and one large The small piece becomes the ldquonewrdquo stomach pouch

bull The larger portion of the stomach stays in place however will lie dormant for the remainder of the patientrsquos life

GASTRIC BYPASS LGB

bull The small intestine (the jejunum) is divided using a surgical staplerApprox 50-70 cm from the DJ Junction

GASTRIC BYPASS LGB

Y- LIMB BP LIMB

bull The end of the Roux limb is then attached to the newly formed stomach pouch which carries food to the distal intestine

bull The Roux loop is completed by forming a jejunostomy

bull The Y limb or BPD limb carries digestive juices from the pancreas gall bladder liver and duodenum to the intestines

bull The food and the digestive juices mix where the Roux limb and Y limb meet much below say 100-150 cm from DJ

Roux limb or alimentary limb

100-150 cm

How Does the Roux-en-Y Work

Surgery factors restriction of meal size ldquodumping syndromerdquo some malabsorption decreased appetite

Patient factors calorie intake calorie expenditure

bull Most commonly performedbull Most reliable operation for long term weight lossbull Long term weight loss averages 60 to 75 percent of EBWbull Malnutrition is unusualbull Substantial improvement amp resolution in many co-morbid

obesity conditions

ADVANTAGES OF RYGBP

1 Not reversible

2 Mortality 05- 1

3 Perioperative complications 5-10

4 Stricture of gastrojejunostomy-10 (long term)

5 Long term risk of protein amp vitamin deficiency and marginal ulceration of GJA

6Long term risk of intestinal obstruction ndash 2

LAPAROSCOPIC GASTRIC BYPASSCOMPLICATIONS

Biliopancreatic Diversion (BPD)

Primarily malabsorptive but restrictive component also

First Terminal ileum is measured to a length of 50 cms marked with suture

The alimentary tract beyond the proximal part of stomach is rearranged to

include only distal 200 cm of ileum including common channel

Common channel-Distal 50 cm of terminal ileum for absorption of fat and

protein

The proximal end of ileum anastomosed to proximal end of stomach after

performing distal hemigastrectomy

Biliopancreatic Diversion with Duodenal Switch

Modification to lessen high incidence of vit b12 deficiency anastomotic stricture at gastrojejunal anastomosis

This procedure involves a sleeve gastrectomy that is then diverted at the duodenum into the ileum at a point measured proximally from the ileocecal valve (usually 250 cm)

The distal duodenum and jejunum the biliopancreatic limb are then anastomosed to the ileum at a point measured proximally from the ileocecal valve (usually 100 cm)

Common channel is 100cm Entire alimentary tract is 250 cm This is the most aggressive bypass procedure commonly offered today Major difference-Sleeve gastrectomy instead of distal hemigastrectomy

bull Most women regained normal menstrual function and most had documented

spontaneous ovulation

bull Significant improvement in hirsutism androgen profiles and about a 50 reduction in

HOMA-IR

bull Follow up for more than 2 years showed that all women resumed normal menstrual

cycles HbA1C decreased from 82 to 51 in lt 3 months

bull 78 saw improvement in metabolic syndrome amp 48 showed improvement in PCOS

2 ROLE OF BARIATRIC SURGERY IN PCOS PATIENTS

bull Decrease menstrual irregularities bull PCOS women have less hyper androgenism

bull Sex hormone binding globulin increases bull LH and FSH levels have been reported to increase

bull Ovulatory function measured by luteal LH and Progesterone secretion improved bull Leptin levels decrease reflecting improved reproductive metabolic status

bull Subclinical hypothyroidism significantly reduced

THE SAFE TIMING OF PREGNANCYoptimal or minimal time gt12 months after bariatric surgery before becoming pregnant in order to allow the rapid weight loss and metabolic changes to subside

4 BARIATRIC SURGERY IN REPRODUCTIVE WOMEN

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)

The foregut hypothesis theory ndash 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

Effect of Bariatric Surgery on Diabetes Mellitus

Combined Gastric Restriction amp Malabsorption

Operative Risks (vs cholecystectomy)

Perioperative Mortality 1-2 vs 02-08 Early Complications 10 vs 29Late Complications 20 vs 1-2

LimitationsWidening of (unbanded) gastrojejunostomyExpansion of gastric pouch 25 with nearly 100 weight regainAdaptation of limb that receives the food

SUMMARY OF ALL TYPES OF SURGERY

bull LRYGBP ndash worlds best procedure 60-70 WL dumping syndrome malnutrition

bull LAGB- low complications varying range of wt loss frequent post-op visits ( 10)

bull DSBPD- more wt loss high complications good for high BMI gt 50 malabsorption +

bull VBG(vertical band gastroplasty) ndash longest available results good wt loss improved co-morbidities right for some ptsrisks too high to justify rewards

bull SG- needs long term research 1st step procedure low risks higher wt loss lesser complications pouch could Stretch over time long staple line could cause problems in future frequency is accelerating because of technical ease 1st stage procedure before bypass

Post-surgical Complications

Anastomosis leaks or staple line leaks Pulmonary Embolism or DVT Cholelithiasis Stomal ulceration Dumping syndrome Constipation

Anastamosis Leaks

Up to 7-10 days after surgery Most common at gastrojejunostomy enteroenterostomy Roux

limb stump staple line Can lead to peritonitis sepsis possible death Presentation

Tachycardia tachypnea Fever Ab painback pain Pelvic pressure or rebound tenderness

Anastamosis Leaks

Order Gastrograffin upper GI series Subclinical cases

Bowel rest Parenteral nutrition IV antibiotic if H pylori

Clinically suspect leak Laparoscopic evaluation and leak repair

Failure to evaluate is the most common cause of preventable major long-term disability or death in bariatric surgical patients

Pulmonary Embolism

Sudden cause of death up to one month after surgery 20-30 mortality rate High risk may have vena cava filter placement prior to surgery Prophylaxis with compression stockings and LMWH Early ambulation imperitive

Pulmonary Embolism

Presentation Profound hypoxia Hypotension Signs of sepsis

Immediate spiral chest CT Abdominal exploration if too large for machine No pathology start anticoagulation Too largehelliphellipNO SURGERY

Cholelithiasis

Up to 36 of patients within 6 months post-op Bile stasis leads to increased sludge and gallstones Prophylactic cholecystectomy prior to surgery if

evidence of existing sludge or stones Prevent post-operative disease with concurrent bariatric

surgery and cholecystectomy Prophylactic use of urosidol

Expensive and unpalatable

Stomal Ulceration

12-15 within 2-4 mos Post-surgery Etiology

Overabundant acid in pouch leads to excessive acid passing through stoma

Pouch tension and staple line breakdown NSAID use

Presentation Dyspepsia vomiting Epigastric or retrosternal pain

Stomal Ulceration

Treatment PPI carafate Antibiotics if H Pylori Avoid NSAIDS alcohol smoking

If no response to treatment Endoscopy Back to surgery for pouch revision or staple line repair

Dumping Syndrome

More than 15 patients Hypotention Tachycardia Lightheadedness syncope Flushing Abdominal cramping and diarrhea Nausea and vomiting

Dumping Syndrome

Occurs with high dose simple sugar ingestion Sugar in small intestine causes osmotic overload and fluid

shift from blood to intestine Increased intestinal volume leads to watery diarrhea Decreased blood volume leads to systemic changes Patient education

Eat slowly Avoid drinking before during and not until 30 minutes after meals

Constipation

Most common complaint Causes

Dehydration and decreased fluid intake post-operatively Increased metabolic water needs Calcium and iron supplement use following surgery

Treat with increased fluids and stool softeners

Nutritional Consequences

Iron deficiency anemia B12 deficiency Folate deficiency Calcium and Vitamin D deficiency

Not seen with purely restrictive surgeries

Iron deficiency and anemia

Common following RYGB As high as 49 of patients Multifactorial cause

Low gastric acid levels prohibit iron cleavage from food Absorption inhibited because no nutrient exposure to duodenum or

proximal jejunum Decrease in iron-rich food consumption due to intolerance

Treat with oral supplementation of ferrous sulfate or ferrous gluconate

Vitamin B12 deficiency

Up to 70 of patients Lack of hydrochloric acid and pepsin in stomach

Prevents B12 cleavage from food Affects secretion of intrinsic factor thus B12 absorption

Intolerance to meat and milk Oral supplementation usually adequate otherwise IM injections used

Folate Deficiency

40 of gastric bypass patients Complete absorption requires B12 Absorption dependent on HCl and upper 13 stomach Deficiency generally caused by decreased consumption Oral supplementation

Vitamin D and Calcium Deficiency

Vitamin D deficiency is common among obese people Calcium absorption decreased because duodenum is

bypassed Intolerance to dairy foods high in calcium Vitamin D is required for Ca++ absorption Prolonged deficiencies lead to

Bone resorption osteomalacia osteoporosis Treat with calcium citrate supplementation and 2 weekly

doses of Vitamin D

Nutritional Implications of Various Bariatric Surgeries(34)

bull RYGB Malabsorption of Vit B12 Vit B1 (thiamin) Vit D Vit K Folate Iron Calcium

bull LAGB Folic Acid deficiency

bull BPD and BPDDS Vit A D E and K deficiency Protein-Calorie Malnutrition Malabsorption of

Calcium Zinc Selenium Sodium Potassium Chloride Phosphorus Magnesium

Recommended Daily Supplements(4)

Multivitamin with iron (prenatal vitamin will have adeq amount of folic acid)

Calcium (citrate) with vitamin D (1200-1500 mg calcium with 800-1000 IU vitamin D)

Oral vitamin B12 (500-1000 mcg) Iron (65 mgday in elemental form)

Vitamin C (to increase absorption of Iron) Thiamin (10 mgday)

Diet Recommendations(3)

Reduce food volume Chew food very well Slow pace of eating No liquids with meals Encourage fruits and vegetables as diet progresses Include high protein foods (at least 60gday) may need protein

supplements

Diet Progression Gastric Bypass

Stage 1 Clear liquids and protein supplement (1 week)

Stage 2No concentrated sweets low fat puree diet ( 3 weeks)

Stage 3 Regular texture weight reduction diet

Diet Progression Lap - Band

Stage 1 Clear liquids and protein supplement ( 2 weeks)

Stage 2 No concentrated sweets low fat puree diet (2weeks)

Stage 3 Regular texture weight reduction diet

Stage 1

Only clear liquids allowed Avoid sweetened beverages Sip very slowly No straws Avoid caffeinated carbonated and alcoholic beverages STOP drinking if you feel fullness pain or discomfort

Protein supplements

Begin the day after you go home from Hospital

Minimum protein target 70gmsday

May use powder or pre-mixed liquid forms (Whey protein is preferred)

Protein pills may not be used

Vitamin and Mineral Supplements

Gastric bypass patients In addition to eating much less food gastric bypass patients will also

absorb vitamins and minerals differently after surgery They will require daily multivitamin calcium and iron

supplementation for the rest of your life

Vitamin and Mineral Supplements

Lap-Bandreg patients

Require a multivitamin with minerals daily

It may be necessary to take additional vitamins and minerals eg calcium iron folateB1 B12These will be prescribed as needed

Stage 2 dietPUREE

Puree diet

Regular scheduled meals Avoid meal skipping Plan meals in advance Eat Slowly Eat protein foods first Moisten meats Use liquid protein as supplement not as meal replacement

Measure 2 oz portions at each meal eating when full Separate liquids and solids No bread rice or pasta Avoid added sugars and high fat

foods VARIETY

Investigationshellip Recommended preoperative laboratory evaluations include

fasting blood glucose lipid profile electrolytes serum chemistries (to evaluate renal and hepatic function) complete blood count Serum ferritin vitamin B12 thyrotropin amp 25-hydroxyvitamin D

(Miller 7th edition- anesthesia for Bariatic Surgery) ABG measurements help evaluate ventilation as well as the need for perioperative oxygen administration and

postoperative ventilation Routine pulmonary function tests and liver function tests are not cost-effective in asymptomatic obese patients Coaugulation profile ( liver problem repeat surgery orlistat) ECG echocardiography Sleep study if suspected OSA

(Barash 6th edition anesthesia and obesity)

Concurrent Preoperative and Prophylactic Medications

Patients usual medications should be continued until the time of surgery with the possible exception of insulin and oral hypoglycemics

Antibiotic prophylaxis is usually indicated

Obesity itself does not increase the risk for aspiration acid aspiration prophylaxis including H2 receptor agonists or proton pump inhibitors must be considered in patients with identifiable risk for aspiration

Anxiolysis and prophylaxis against deep vein thrombosis (DVT) should be addressed at premedication

DVT consideration Morbid obesity is a major independent risk factor for sudden death from

acute postoperative pulmonary embolism Subcutaneous heparin 5000 IU administered before surgery and repeated every 8 to 12

hours until the patient is fully mobile reduces the risk of DVT LMWH can also be used

Preoperative prophylactic placement of an inferior vena cava filter should be considered in venous stasis disease BMI ge60 truncal obesity and OSA

What Are the Risks

MAJOR RISKS Death (1 of patients die within 30 days) Severe malnutrition (anemia PEM osteomalacia) Peritonitis (from leakage or ruptures at staple sites)

or other infection Obstructions caused by scar tissue in the stomach or

bowels

MINOR RISKS Dumping Syndrome (unpleasant but not harmful) Diarrhea and malodorous gas production Lactose intolerance Hair loss (short-term post-surgery) May have to eventually undergo surgical revision Pain post-surgery

History of Bariatric Surgery

Obesity surgery is not a new discipline The earliest Bariatric procedure performed was in 1954 at Minnesota The procedure

was Jejuno-ileal bypass In 1966Gastric Bypass was introduced as a surgical procedure for weight loss at the

University of Iowa In 1977Griffen reported the first Roux-en-Y Gastric Bypass In 1980surgeons with a more conservative approach developed the Vertical Banded

Gastroplasty Other procedures with longer intestinal segment bypass were also introduced such as

Biliopancreatic Diversions These complex procedures are recommended in super-obese patients ie BMIgt60

How does surgery work

RESTRICTIVE - RESTRICT AMOUNT OF FOOD INGESTED Decreases appetitehunger

Early satiety Behavior modification Gastric Banding (Lap Band)

Roux-en Y Gastric bypass (RYGB) Sleeve Gastrectomy

MALABSORPTIVE- LIMITS DIGESTION AND ABSORPTION Decreases length of intestine exposed to digested food

25 of fat is absorbed Behavior modification

Biliopancreatic Diversion Duodenal Switch (BPDDS)

ALL OPERATIONS CAN BE PERFORMED OPEN OR LAPAROSCOPICALLY

Laparoscopic vs Open

OPEN uarr post op pain Longer hospitalizations uarr wound complications

Infection Hernias Seromas

Return to work in 4-8 weeks

LAPAROSCOPIC darr post op pain Early mobility darr Wound complications 2-3 day hospital stay Return to work in 1-3 weeks

1 Nguyen NT et al Accelerated growth of bariatric surgery with the introduction of minimally invasive surgery Arch Surg 20051401198-202

Procedures that are solely restrictive by creating a small gastric pouch of volume 15 to 30 cc amp a degree of outlet obstruction leading to delayed gastric emptying The goal is to reduce oral intake by limiting gastric volume produce early satiety and leave the alimentary canal in continuity minimizing the risks of metabolic complications

1VERTICAL BANDED GASTROPLASTY

2ADJUSTABLE GASTRIC BANDING (LAGB )

3 SLEEVE GASTRECTOMY

4GASTRIC PLICATION

5 INTRA GASTRIC BALLOON (GASTRIC BALLOON)

RESTRICTIVE PROCEDURES

Malabsorption is achieved by creating a short gut syndrome andor by accomplishing distal mixing of bile and pancreatic juice with ingested nutrients thereby reducing absorption Some purely malabsorptive operations are no longer recommended due to their potential hazard to cause serious nutritional deficiencies

1 BILIOPANCREATIC DIVERSION2 THE JEJUNAL-ILEAL BYPASS3 ENDOLUMINAL SLEEVE

MALABSORPTIVE PROCEDURES

MIXED PROCEDURES

1GASTRIC BYPASS ROUX-EN-Y ( RYGBP)

2SLEEVE GASTRECTOMY WITH DUODENAL SWITCH

3IMPLANTABLE 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

The stomach is partitioned along its axis with a non-

adjustable poly-urethane band and with linear amp 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 was practiced in 1980

Vertical Banded Gastroplasty (VBG)

ADJUSTABLE GASTRIC BANDING (LAP BAND SURGERY LAGB)

Restrictive Procedure The procedure was first performed by Cadiere in 1992 but was made popular by Belachew and Legrand in 1993 An inflatable silicone BAND is placed around the top portion of the stomach to form a small stomach pouch amp sewed

This band is connected to a tube that leads to a port above the abdominal muscles placed below the skin (FILL ndash PORT)

During follow up visits we inject or remove saline solution to make the band tighter or looser

Adjustable Gastric Band

bull 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

How does the Band work

Surgery Factors Restriction of meal size Decreased appetite

Patient Factors Decreased calorie intake Increased calorie expenditure

LAP-BAND Adjustability

Unfilled Band Filled Band

Adjustments are made in the office

Complications of Gastric Lap-Band

bull Perforation of Stomachbull Slippagebull Gastric Erosion(much less after Pars flaccida technique) bull Dilated Esophagusbull Tubing access port problemsbull Mal positioningbull Abdominal Painbull Heartburnbull Vomitingbull Inability to Adjust the Bandbull Failure to Lose Weightbull Infection of Systembull Fatigue or malfunction

Advantages

No intestinal surgery No staplingcutting of stomach No nutritional risks Adjustable Reversible Safe

Foreign body Frequent follow-up visits Needs more commitment Easy to cheat

Disadvantages

Comparison of Adjustable Gastric Banding and Vertical Banded Gastroplasty

Laparoscopic adjustable gastric banding Reversible Adjustable Simpler to perform laparoscopically Sustained weight loss of gt50 EBW gt5

years following surgery Complications Gastric prolapse band

erosion rarely gastric perforation and access port complications

Vertical banded gastroplasty Irreversible Non adjustable Technically difficult by laparoscopy Weight loss of 25-50 EBW and weight gain

after 2-3 years Complications suture line disruption gastric

leak weight gain

>

>

Originally used as the first-stage operation for a proposed biliopancreatic diversion with duodenal switch in high-risk patients

The sleeve gastrectomy has caught on as a primary obesity treatment as surgeons are reporting weight loss of 55 of excess body weight past 5 years in some patients

The sleeve gastrectomy is also known as the greater curvature gastrectomy vertical or longitudinal gastrectomy or Pylorus preserving lsquogastric tube creationrsquo

Rapid and less traumatic operation Good resolution of co-morbidities and good weight loss

A further second surgical step is then easily feasible if necessary

SLEEVE GASTRECTOMY

SLEEVE GASTRECTOMY

A sleeve gastrectomy involves resection of

approximately 80 of the greater curvature

side of the stomach

Smaller tubular gastric ldquosleeverdquo created

along the lesser curve that is based on the

lesser curvature blood supply

Ideal approximate capacity of the stomach

after the procedure is about 30- 60 ml pouch

1MECHANICAL RESTRICTION by reducing the volume of the stomach and impairing stomach mobility Also called lsquoFood limitingrsquo operation

2HORMONAL MODIFICATION by removing a great part of the Ghrelin (Hunger Hormone) production tissue

(Ghrelin is a 28 amino-acid-peptide secreted by the oxyntic glands of the gastric fungus It is a potent orexigenic (appetite-stimulating) peptide mediated by the activation of its receptors in the hypothalamus or pituitary area)

The gastric fundus contains 10 to 20 times more ghrelin per one gram of tissue than the duodenum In the SG resection of the fundus removes the major portion of ghrelin release therefore appetite decreases

The sleeve gastrectomy (SG) induces weight loss by 2 mechanisms

>

Intragastric balloon involves placing a deflated balloon into the stomach and then filling it to decrease the amount of gastric space

The balloon can be left in the stomach for a maximum of 6 months and results in an average weight loss of 5ndash9 BMI over half a year

Done endoscopically

The intragastric balloon may be used prior to another bariatric surgery as a step-down procedure

INTRA GASTRIC BALLOON

>

>

The EndoBarrier gastrointestinal liner mimics the effects of gastric bypass surgery

Itrsquos designed to work by inserting a flexible

tube-like barrier into the duodenum amp 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

ENDO BARRIER LINER SYSTEM

B MAL- ABSORPTIVE PROCEDURES

Malabsorptive surgeries rearrange andor remove part of digestive system which then limits the amount of calories and nutrients that body can absorb Treatment with a large malabsorptive component results in the most weight loss but tend to have slightly higher complication rates

1JEJUNAL ILEAL BYPASS ndash no longer performed for high complication rates

2ILEAL TRANSPOSITION- New malabsoptive procedure on trial for treatment of DM type 2 and metabolic disorders

C COMBINATION PROCEDURES RESTRICTIVE + MALABSORBTIVE

1LAP GASTRIC BYPASS ndash ROUX-EN- Y ndash more malabsorption than the restrictive

2MINI- GASTRIC BYPASS- mainly restrictive

3DUODENAL SWITCH ndash the sleeve stomach is the restrictive portion ampthe intestinal bypass (duodenal switch) is the malabsorptive component

When surgery combines both restrictive and malabsorptive techniques it is know as a ldquocombinationrdquo procedure Most types of bariatric surgery carry at least a small element of both components but the following surgeries achieve a notable portion of weight loss from eachhellip

1 LAP GASTRIC BYPASS LGB

The Roux-en-Y gastric bypass(known simply as the LRYGBP) is the most commonly performed procedure

It primarily causesweight loss by restricting thefood intake however there ismore amount of mal absorption that occurs with this operation

GASTRIC BYPASS LRYGBP

bullThe stomach is stapled into2 pieces one small and one large The small piece becomes the ldquonewrdquo stomach pouch

bull The larger portion of the stomach stays in place however will lie dormant for the remainder of the patientrsquos life

GASTRIC BYPASS LGB

bull The small intestine (the jejunum) is divided using a surgical staplerApprox 50-70 cm from the DJ Junction

GASTRIC BYPASS LGB

Y- LIMB BP LIMB

bull The end of the Roux limb is then attached to the newly formed stomach pouch which carries food to the distal intestine

bull The Roux loop is completed by forming a jejunostomy

bull The Y limb or BPD limb carries digestive juices from the pancreas gall bladder liver and duodenum to the intestines

bull The food and the digestive juices mix where the Roux limb and Y limb meet much below say 100-150 cm from DJ

Roux limb or alimentary limb

100-150 cm

How Does the Roux-en-Y Work

Surgery factors restriction of meal size ldquodumping syndromerdquo some malabsorption decreased appetite

Patient factors calorie intake calorie expenditure

bull Most commonly performedbull Most reliable operation for long term weight lossbull Long term weight loss averages 60 to 75 percent of EBWbull Malnutrition is unusualbull Substantial improvement amp resolution in many co-morbid

obesity conditions

ADVANTAGES OF RYGBP

1 Not reversible

2 Mortality 05- 1

3 Perioperative complications 5-10

4 Stricture of gastrojejunostomy-10 (long term)

5 Long term risk of protein amp vitamin deficiency and marginal ulceration of GJA

6Long term risk of intestinal obstruction ndash 2

LAPAROSCOPIC GASTRIC BYPASSCOMPLICATIONS

Biliopancreatic Diversion (BPD)

Primarily malabsorptive but restrictive component also

First Terminal ileum is measured to a length of 50 cms marked with suture

The alimentary tract beyond the proximal part of stomach is rearranged to

include only distal 200 cm of ileum including common channel

Common channel-Distal 50 cm of terminal ileum for absorption of fat and

protein

The proximal end of ileum anastomosed to proximal end of stomach after

performing distal hemigastrectomy

Biliopancreatic Diversion with Duodenal Switch

Modification to lessen high incidence of vit b12 deficiency anastomotic stricture at gastrojejunal anastomosis

This procedure involves a sleeve gastrectomy that is then diverted at the duodenum into the ileum at a point measured proximally from the ileocecal valve (usually 250 cm)

The distal duodenum and jejunum the biliopancreatic limb are then anastomosed to the ileum at a point measured proximally from the ileocecal valve (usually 100 cm)

Common channel is 100cm Entire alimentary tract is 250 cm This is the most aggressive bypass procedure commonly offered today Major difference-Sleeve gastrectomy instead of distal hemigastrectomy

bull Most women regained normal menstrual function and most had documented

spontaneous ovulation

bull Significant improvement in hirsutism androgen profiles and about a 50 reduction in

HOMA-IR

bull Follow up for more than 2 years showed that all women resumed normal menstrual

cycles HbA1C decreased from 82 to 51 in lt 3 months

bull 78 saw improvement in metabolic syndrome amp 48 showed improvement in PCOS

2 ROLE OF BARIATRIC SURGERY IN PCOS PATIENTS

bull Decrease menstrual irregularities bull PCOS women have less hyper androgenism

bull Sex hormone binding globulin increases bull LH and FSH levels have been reported to increase

bull Ovulatory function measured by luteal LH and Progesterone secretion improved bull Leptin levels decrease reflecting improved reproductive metabolic status

bull Subclinical hypothyroidism significantly reduced

THE SAFE TIMING OF PREGNANCYoptimal or minimal time gt12 months after bariatric surgery before becoming pregnant in order to allow the rapid weight loss and metabolic changes to subside

4 BARIATRIC SURGERY IN REPRODUCTIVE WOMEN

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)

The foregut hypothesis theory ndash 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

Effect of Bariatric Surgery on Diabetes Mellitus

Combined Gastric Restriction amp Malabsorption

Operative Risks (vs cholecystectomy)

Perioperative Mortality 1-2 vs 02-08 Early Complications 10 vs 29Late Complications 20 vs 1-2

LimitationsWidening of (unbanded) gastrojejunostomyExpansion of gastric pouch 25 with nearly 100 weight regainAdaptation of limb that receives the food

SUMMARY OF ALL TYPES OF SURGERY

bull LRYGBP ndash worlds best procedure 60-70 WL dumping syndrome malnutrition

bull LAGB- low complications varying range of wt loss frequent post-op visits ( 10)

bull DSBPD- more wt loss high complications good for high BMI gt 50 malabsorption +

bull VBG(vertical band gastroplasty) ndash longest available results good wt loss improved co-morbidities right for some ptsrisks too high to justify rewards

bull SG- needs long term research 1st step procedure low risks higher wt loss lesser complications pouch could Stretch over time long staple line could cause problems in future frequency is accelerating because of technical ease 1st stage procedure before bypass

Post-surgical Complications

Anastomosis leaks or staple line leaks Pulmonary Embolism or DVT Cholelithiasis Stomal ulceration Dumping syndrome Constipation

Anastamosis Leaks

Up to 7-10 days after surgery Most common at gastrojejunostomy enteroenterostomy Roux

limb stump staple line Can lead to peritonitis sepsis possible death Presentation

Tachycardia tachypnea Fever Ab painback pain Pelvic pressure or rebound tenderness

Anastamosis Leaks

Order Gastrograffin upper GI series Subclinical cases

Bowel rest Parenteral nutrition IV antibiotic if H pylori

Clinically suspect leak Laparoscopic evaluation and leak repair

Failure to evaluate is the most common cause of preventable major long-term disability or death in bariatric surgical patients

Pulmonary Embolism

Sudden cause of death up to one month after surgery 20-30 mortality rate High risk may have vena cava filter placement prior to surgery Prophylaxis with compression stockings and LMWH Early ambulation imperitive

Pulmonary Embolism

Presentation Profound hypoxia Hypotension Signs of sepsis

Immediate spiral chest CT Abdominal exploration if too large for machine No pathology start anticoagulation Too largehelliphellipNO SURGERY

Cholelithiasis

Up to 36 of patients within 6 months post-op Bile stasis leads to increased sludge and gallstones Prophylactic cholecystectomy prior to surgery if

evidence of existing sludge or stones Prevent post-operative disease with concurrent bariatric

surgery and cholecystectomy Prophylactic use of urosidol

Expensive and unpalatable

Stomal Ulceration

12-15 within 2-4 mos Post-surgery Etiology

Overabundant acid in pouch leads to excessive acid passing through stoma

Pouch tension and staple line breakdown NSAID use

Presentation Dyspepsia vomiting Epigastric or retrosternal pain

Stomal Ulceration

Treatment PPI carafate Antibiotics if H Pylori Avoid NSAIDS alcohol smoking

If no response to treatment Endoscopy Back to surgery for pouch revision or staple line repair

Dumping Syndrome

More than 15 patients Hypotention Tachycardia Lightheadedness syncope Flushing Abdominal cramping and diarrhea Nausea and vomiting

Dumping Syndrome

Occurs with high dose simple sugar ingestion Sugar in small intestine causes osmotic overload and fluid

shift from blood to intestine Increased intestinal volume leads to watery diarrhea Decreased blood volume leads to systemic changes Patient education

Eat slowly Avoid drinking before during and not until 30 minutes after meals

Constipation

Most common complaint Causes

Dehydration and decreased fluid intake post-operatively Increased metabolic water needs Calcium and iron supplement use following surgery

Treat with increased fluids and stool softeners

Nutritional Consequences

Iron deficiency anemia B12 deficiency Folate deficiency Calcium and Vitamin D deficiency

Not seen with purely restrictive surgeries

Iron deficiency and anemia

Common following RYGB As high as 49 of patients Multifactorial cause

Low gastric acid levels prohibit iron cleavage from food Absorption inhibited because no nutrient exposure to duodenum or

proximal jejunum Decrease in iron-rich food consumption due to intolerance

Treat with oral supplementation of ferrous sulfate or ferrous gluconate

Vitamin B12 deficiency

Up to 70 of patients Lack of hydrochloric acid and pepsin in stomach

Prevents B12 cleavage from food Affects secretion of intrinsic factor thus B12 absorption

Intolerance to meat and milk Oral supplementation usually adequate otherwise IM injections used

Folate Deficiency

40 of gastric bypass patients Complete absorption requires B12 Absorption dependent on HCl and upper 13 stomach Deficiency generally caused by decreased consumption Oral supplementation

Vitamin D and Calcium Deficiency

Vitamin D deficiency is common among obese people Calcium absorption decreased because duodenum is

bypassed Intolerance to dairy foods high in calcium Vitamin D is required for Ca++ absorption Prolonged deficiencies lead to

Bone resorption osteomalacia osteoporosis Treat with calcium citrate supplementation and 2 weekly

doses of Vitamin D

Nutritional Implications of Various Bariatric Surgeries(34)

bull RYGB Malabsorption of Vit B12 Vit B1 (thiamin) Vit D Vit K Folate Iron Calcium

bull LAGB Folic Acid deficiency

bull BPD and BPDDS Vit A D E and K deficiency Protein-Calorie Malnutrition Malabsorption of

Calcium Zinc Selenium Sodium Potassium Chloride Phosphorus Magnesium

Recommended Daily Supplements(4)

Multivitamin with iron (prenatal vitamin will have adeq amount of folic acid)

Calcium (citrate) with vitamin D (1200-1500 mg calcium with 800-1000 IU vitamin D)

Oral vitamin B12 (500-1000 mcg) Iron (65 mgday in elemental form)

Vitamin C (to increase absorption of Iron) Thiamin (10 mgday)

Diet Recommendations(3)

Reduce food volume Chew food very well Slow pace of eating No liquids with meals Encourage fruits and vegetables as diet progresses Include high protein foods (at least 60gday) may need protein

supplements

Diet Progression Gastric Bypass

Stage 1 Clear liquids and protein supplement (1 week)

Stage 2No concentrated sweets low fat puree diet ( 3 weeks)

Stage 3 Regular texture weight reduction diet

Diet Progression Lap - Band

Stage 1 Clear liquids and protein supplement ( 2 weeks)

Stage 2 No concentrated sweets low fat puree diet (2weeks)

Stage 3 Regular texture weight reduction diet

Stage 1

Only clear liquids allowed Avoid sweetened beverages Sip very slowly No straws Avoid caffeinated carbonated and alcoholic beverages STOP drinking if you feel fullness pain or discomfort

Protein supplements

Begin the day after you go home from Hospital

Minimum protein target 70gmsday

May use powder or pre-mixed liquid forms (Whey protein is preferred)

Protein pills may not be used

Vitamin and Mineral Supplements

Gastric bypass patients In addition to eating much less food gastric bypass patients will also

absorb vitamins and minerals differently after surgery They will require daily multivitamin calcium and iron

supplementation for the rest of your life

Vitamin and Mineral Supplements

Lap-Bandreg patients

Require a multivitamin with minerals daily

It may be necessary to take additional vitamins and minerals eg calcium iron folateB1 B12These will be prescribed as needed

Stage 2 dietPUREE

Puree diet

Regular scheduled meals Avoid meal skipping Plan meals in advance Eat Slowly Eat protein foods first Moisten meats Use liquid protein as supplement not as meal replacement

Measure 2 oz portions at each meal eating when full Separate liquids and solids No bread rice or pasta Avoid added sugars and high fat

foods VARIETY

Concurrent Preoperative and Prophylactic Medications

Patients usual medications should be continued until the time of surgery with the possible exception of insulin and oral hypoglycemics

Antibiotic prophylaxis is usually indicated

Obesity itself does not increase the risk for aspiration acid aspiration prophylaxis including H2 receptor agonists or proton pump inhibitors must be considered in patients with identifiable risk for aspiration

Anxiolysis and prophylaxis against deep vein thrombosis (DVT) should be addressed at premedication

DVT consideration Morbid obesity is a major independent risk factor for sudden death from

acute postoperative pulmonary embolism Subcutaneous heparin 5000 IU administered before surgery and repeated every 8 to 12

hours until the patient is fully mobile reduces the risk of DVT LMWH can also be used

Preoperative prophylactic placement of an inferior vena cava filter should be considered in venous stasis disease BMI ge60 truncal obesity and OSA

What Are the Risks

MAJOR RISKS Death (1 of patients die within 30 days) Severe malnutrition (anemia PEM osteomalacia) Peritonitis (from leakage or ruptures at staple sites)

or other infection Obstructions caused by scar tissue in the stomach or

bowels

MINOR RISKS Dumping Syndrome (unpleasant but not harmful) Diarrhea and malodorous gas production Lactose intolerance Hair loss (short-term post-surgery) May have to eventually undergo surgical revision Pain post-surgery

History of Bariatric Surgery

Obesity surgery is not a new discipline The earliest Bariatric procedure performed was in 1954 at Minnesota The procedure

was Jejuno-ileal bypass In 1966Gastric Bypass was introduced as a surgical procedure for weight loss at the

University of Iowa In 1977Griffen reported the first Roux-en-Y Gastric Bypass In 1980surgeons with a more conservative approach developed the Vertical Banded

Gastroplasty Other procedures with longer intestinal segment bypass were also introduced such as

Biliopancreatic Diversions These complex procedures are recommended in super-obese patients ie BMIgt60

How does surgery work

RESTRICTIVE - RESTRICT AMOUNT OF FOOD INGESTED Decreases appetitehunger

Early satiety Behavior modification Gastric Banding (Lap Band)

Roux-en Y Gastric bypass (RYGB) Sleeve Gastrectomy

MALABSORPTIVE- LIMITS DIGESTION AND ABSORPTION Decreases length of intestine exposed to digested food

25 of fat is absorbed Behavior modification

Biliopancreatic Diversion Duodenal Switch (BPDDS)

ALL OPERATIONS CAN BE PERFORMED OPEN OR LAPAROSCOPICALLY

Laparoscopic vs Open

OPEN uarr post op pain Longer hospitalizations uarr wound complications

Infection Hernias Seromas

Return to work in 4-8 weeks

LAPAROSCOPIC darr post op pain Early mobility darr Wound complications 2-3 day hospital stay Return to work in 1-3 weeks

1 Nguyen NT et al Accelerated growth of bariatric surgery with the introduction of minimally invasive surgery Arch Surg 20051401198-202

Procedures that are solely restrictive by creating a small gastric pouch of volume 15 to 30 cc amp a degree of outlet obstruction leading to delayed gastric emptying The goal is to reduce oral intake by limiting gastric volume produce early satiety and leave the alimentary canal in continuity minimizing the risks of metabolic complications

1VERTICAL BANDED GASTROPLASTY

2ADJUSTABLE GASTRIC BANDING (LAGB )

3 SLEEVE GASTRECTOMY

4GASTRIC PLICATION

5 INTRA GASTRIC BALLOON (GASTRIC BALLOON)

RESTRICTIVE PROCEDURES

Malabsorption is achieved by creating a short gut syndrome andor by accomplishing distal mixing of bile and pancreatic juice with ingested nutrients thereby reducing absorption Some purely malabsorptive operations are no longer recommended due to their potential hazard to cause serious nutritional deficiencies

1 BILIOPANCREATIC DIVERSION2 THE JEJUNAL-ILEAL BYPASS3 ENDOLUMINAL SLEEVE

MALABSORPTIVE PROCEDURES

MIXED PROCEDURES

1GASTRIC BYPASS ROUX-EN-Y ( RYGBP)

2SLEEVE GASTRECTOMY WITH DUODENAL SWITCH

3IMPLANTABLE 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

The stomach is partitioned along its axis with a non-

adjustable poly-urethane band and with linear amp 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 was practiced in 1980

Vertical Banded Gastroplasty (VBG)

ADJUSTABLE GASTRIC BANDING (LAP BAND SURGERY LAGB)

Restrictive Procedure The procedure was first performed by Cadiere in 1992 but was made popular by Belachew and Legrand in 1993 An inflatable silicone BAND is placed around the top portion of the stomach to form a small stomach pouch amp sewed

This band is connected to a tube that leads to a port above the abdominal muscles placed below the skin (FILL ndash PORT)

During follow up visits we inject or remove saline solution to make the band tighter or looser

Adjustable Gastric Band

bull 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

How does the Band work

Surgery Factors Restriction of meal size Decreased appetite

Patient Factors Decreased calorie intake Increased calorie expenditure

LAP-BAND Adjustability

Unfilled Band Filled Band

Adjustments are made in the office

Complications of Gastric Lap-Band

bull Perforation of Stomachbull Slippagebull Gastric Erosion(much less after Pars flaccida technique) bull Dilated Esophagusbull Tubing access port problemsbull Mal positioningbull Abdominal Painbull Heartburnbull Vomitingbull Inability to Adjust the Bandbull Failure to Lose Weightbull Infection of Systembull Fatigue or malfunction

Advantages

No intestinal surgery No staplingcutting of stomach No nutritional risks Adjustable Reversible Safe

Foreign body Frequent follow-up visits Needs more commitment Easy to cheat

Disadvantages

Comparison of Adjustable Gastric Banding and Vertical Banded Gastroplasty

Laparoscopic adjustable gastric banding Reversible Adjustable Simpler to perform laparoscopically Sustained weight loss of gt50 EBW gt5

years following surgery Complications Gastric prolapse band

erosion rarely gastric perforation and access port complications

Vertical banded gastroplasty Irreversible Non adjustable Technically difficult by laparoscopy Weight loss of 25-50 EBW and weight gain

after 2-3 years Complications suture line disruption gastric

leak weight gain

>

>

Originally used as the first-stage operation for a proposed biliopancreatic diversion with duodenal switch in high-risk patients

The sleeve gastrectomy has caught on as a primary obesity treatment as surgeons are reporting weight loss of 55 of excess body weight past 5 years in some patients

The sleeve gastrectomy is also known as the greater curvature gastrectomy vertical or longitudinal gastrectomy or Pylorus preserving lsquogastric tube creationrsquo

Rapid and less traumatic operation Good resolution of co-morbidities and good weight loss

A further second surgical step is then easily feasible if necessary

SLEEVE GASTRECTOMY

SLEEVE GASTRECTOMY

A sleeve gastrectomy involves resection of

approximately 80 of the greater curvature

side of the stomach

Smaller tubular gastric ldquosleeverdquo created

along the lesser curve that is based on the

lesser curvature blood supply

Ideal approximate capacity of the stomach

after the procedure is about 30- 60 ml pouch

1MECHANICAL RESTRICTION by reducing the volume of the stomach and impairing stomach mobility Also called lsquoFood limitingrsquo operation

2HORMONAL MODIFICATION by removing a great part of the Ghrelin (Hunger Hormone) production tissue

(Ghrelin is a 28 amino-acid-peptide secreted by the oxyntic glands of the gastric fungus It is a potent orexigenic (appetite-stimulating) peptide mediated by the activation of its receptors in the hypothalamus or pituitary area)

The gastric fundus contains 10 to 20 times more ghrelin per one gram of tissue than the duodenum In the SG resection of the fundus removes the major portion of ghrelin release therefore appetite decreases

The sleeve gastrectomy (SG) induces weight loss by 2 mechanisms

>

Intragastric balloon involves placing a deflated balloon into the stomach and then filling it to decrease the amount of gastric space

The balloon can be left in the stomach for a maximum of 6 months and results in an average weight loss of 5ndash9 BMI over half a year

Done endoscopically

The intragastric balloon may be used prior to another bariatric surgery as a step-down procedure

INTRA GASTRIC BALLOON

>

>

The EndoBarrier gastrointestinal liner mimics the effects of gastric bypass surgery

Itrsquos designed to work by inserting a flexible

tube-like barrier into the duodenum amp 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

ENDO BARRIER LINER SYSTEM

B MAL- ABSORPTIVE PROCEDURES

Malabsorptive surgeries rearrange andor remove part of digestive system which then limits the amount of calories and nutrients that body can absorb Treatment with a large malabsorptive component results in the most weight loss but tend to have slightly higher complication rates

1JEJUNAL ILEAL BYPASS ndash no longer performed for high complication rates

2ILEAL TRANSPOSITION- New malabsoptive procedure on trial for treatment of DM type 2 and metabolic disorders

C COMBINATION PROCEDURES RESTRICTIVE + MALABSORBTIVE

1LAP GASTRIC BYPASS ndash ROUX-EN- Y ndash more malabsorption than the restrictive

2MINI- GASTRIC BYPASS- mainly restrictive

3DUODENAL SWITCH ndash the sleeve stomach is the restrictive portion ampthe intestinal bypass (duodenal switch) is the malabsorptive component

When surgery combines both restrictive and malabsorptive techniques it is know as a ldquocombinationrdquo procedure Most types of bariatric surgery carry at least a small element of both components but the following surgeries achieve a notable portion of weight loss from eachhellip

1 LAP GASTRIC BYPASS LGB

The Roux-en-Y gastric bypass(known simply as the LRYGBP) is the most commonly performed procedure

It primarily causesweight loss by restricting thefood intake however there ismore amount of mal absorption that occurs with this operation

GASTRIC BYPASS LRYGBP

bullThe stomach is stapled into2 pieces one small and one large The small piece becomes the ldquonewrdquo stomach pouch

bull The larger portion of the stomach stays in place however will lie dormant for the remainder of the patientrsquos life

GASTRIC BYPASS LGB

bull The small intestine (the jejunum) is divided using a surgical staplerApprox 50-70 cm from the DJ Junction

GASTRIC BYPASS LGB

Y- LIMB BP LIMB

bull The end of the Roux limb is then attached to the newly formed stomach pouch which carries food to the distal intestine

bull The Roux loop is completed by forming a jejunostomy

bull The Y limb or BPD limb carries digestive juices from the pancreas gall bladder liver and duodenum to the intestines

bull The food and the digestive juices mix where the Roux limb and Y limb meet much below say 100-150 cm from DJ

Roux limb or alimentary limb

100-150 cm

How Does the Roux-en-Y Work

Surgery factors restriction of meal size ldquodumping syndromerdquo some malabsorption decreased appetite

Patient factors calorie intake calorie expenditure

bull Most commonly performedbull Most reliable operation for long term weight lossbull Long term weight loss averages 60 to 75 percent of EBWbull Malnutrition is unusualbull Substantial improvement amp resolution in many co-morbid

obesity conditions

ADVANTAGES OF RYGBP

1 Not reversible

2 Mortality 05- 1

3 Perioperative complications 5-10

4 Stricture of gastrojejunostomy-10 (long term)

5 Long term risk of protein amp vitamin deficiency and marginal ulceration of GJA

6Long term risk of intestinal obstruction ndash 2

LAPAROSCOPIC GASTRIC BYPASSCOMPLICATIONS

Biliopancreatic Diversion (BPD)

Primarily malabsorptive but restrictive component also

First Terminal ileum is measured to a length of 50 cms marked with suture

The alimentary tract beyond the proximal part of stomach is rearranged to

include only distal 200 cm of ileum including common channel

Common channel-Distal 50 cm of terminal ileum for absorption of fat and

protein

The proximal end of ileum anastomosed to proximal end of stomach after

performing distal hemigastrectomy

Biliopancreatic Diversion with Duodenal Switch

Modification to lessen high incidence of vit b12 deficiency anastomotic stricture at gastrojejunal anastomosis

This procedure involves a sleeve gastrectomy that is then diverted at the duodenum into the ileum at a point measured proximally from the ileocecal valve (usually 250 cm)

The distal duodenum and jejunum the biliopancreatic limb are then anastomosed to the ileum at a point measured proximally from the ileocecal valve (usually 100 cm)

Common channel is 100cm Entire alimentary tract is 250 cm This is the most aggressive bypass procedure commonly offered today Major difference-Sleeve gastrectomy instead of distal hemigastrectomy

bull Most women regained normal menstrual function and most had documented

spontaneous ovulation

bull Significant improvement in hirsutism androgen profiles and about a 50 reduction in

HOMA-IR

bull Follow up for more than 2 years showed that all women resumed normal menstrual

cycles HbA1C decreased from 82 to 51 in lt 3 months

bull 78 saw improvement in metabolic syndrome amp 48 showed improvement in PCOS

2 ROLE OF BARIATRIC SURGERY IN PCOS PATIENTS

bull Decrease menstrual irregularities bull PCOS women have less hyper androgenism

bull Sex hormone binding globulin increases bull LH and FSH levels have been reported to increase

bull Ovulatory function measured by luteal LH and Progesterone secretion improved bull Leptin levels decrease reflecting improved reproductive metabolic status

bull Subclinical hypothyroidism significantly reduced

THE SAFE TIMING OF PREGNANCYoptimal or minimal time gt12 months after bariatric surgery before becoming pregnant in order to allow the rapid weight loss and metabolic changes to subside

4 BARIATRIC SURGERY IN REPRODUCTIVE WOMEN

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)

The foregut hypothesis theory ndash 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

Effect of Bariatric Surgery on Diabetes Mellitus

Combined Gastric Restriction amp Malabsorption

Operative Risks (vs cholecystectomy)

Perioperative Mortality 1-2 vs 02-08 Early Complications 10 vs 29Late Complications 20 vs 1-2

LimitationsWidening of (unbanded) gastrojejunostomyExpansion of gastric pouch 25 with nearly 100 weight regainAdaptation of limb that receives the food

SUMMARY OF ALL TYPES OF SURGERY

bull LRYGBP ndash worlds best procedure 60-70 WL dumping syndrome malnutrition

bull LAGB- low complications varying range of wt loss frequent post-op visits ( 10)

bull DSBPD- more wt loss high complications good for high BMI gt 50 malabsorption +

bull VBG(vertical band gastroplasty) ndash longest available results good wt loss improved co-morbidities right for some ptsrisks too high to justify rewards

bull SG- needs long term research 1st step procedure low risks higher wt loss lesser complications pouch could Stretch over time long staple line could cause problems in future frequency is accelerating because of technical ease 1st stage procedure before bypass

Post-surgical Complications

Anastomosis leaks or staple line leaks Pulmonary Embolism or DVT Cholelithiasis Stomal ulceration Dumping syndrome Constipation

Anastamosis Leaks

Up to 7-10 days after surgery Most common at gastrojejunostomy enteroenterostomy Roux

limb stump staple line Can lead to peritonitis sepsis possible death Presentation

Tachycardia tachypnea Fever Ab painback pain Pelvic pressure or rebound tenderness

Anastamosis Leaks

Order Gastrograffin upper GI series Subclinical cases

Bowel rest Parenteral nutrition IV antibiotic if H pylori

Clinically suspect leak Laparoscopic evaluation and leak repair

Failure to evaluate is the most common cause of preventable major long-term disability or death in bariatric surgical patients

Pulmonary Embolism

Sudden cause of death up to one month after surgery 20-30 mortality rate High risk may have vena cava filter placement prior to surgery Prophylaxis with compression stockings and LMWH Early ambulation imperitive

Pulmonary Embolism

Presentation Profound hypoxia Hypotension Signs of sepsis

Immediate spiral chest CT Abdominal exploration if too large for machine No pathology start anticoagulation Too largehelliphellipNO SURGERY

Cholelithiasis

Up to 36 of patients within 6 months post-op Bile stasis leads to increased sludge and gallstones Prophylactic cholecystectomy prior to surgery if

evidence of existing sludge or stones Prevent post-operative disease with concurrent bariatric

surgery and cholecystectomy Prophylactic use of urosidol

Expensive and unpalatable

Stomal Ulceration

12-15 within 2-4 mos Post-surgery Etiology

Overabundant acid in pouch leads to excessive acid passing through stoma

Pouch tension and staple line breakdown NSAID use

Presentation Dyspepsia vomiting Epigastric or retrosternal pain

Stomal Ulceration

Treatment PPI carafate Antibiotics if H Pylori Avoid NSAIDS alcohol smoking

If no response to treatment Endoscopy Back to surgery for pouch revision or staple line repair

Dumping Syndrome

More than 15 patients Hypotention Tachycardia Lightheadedness syncope Flushing Abdominal cramping and diarrhea Nausea and vomiting

Dumping Syndrome

Occurs with high dose simple sugar ingestion Sugar in small intestine causes osmotic overload and fluid

shift from blood to intestine Increased intestinal volume leads to watery diarrhea Decreased blood volume leads to systemic changes Patient education

Eat slowly Avoid drinking before during and not until 30 minutes after meals

Constipation

Most common complaint Causes

Dehydration and decreased fluid intake post-operatively Increased metabolic water needs Calcium and iron supplement use following surgery

Treat with increased fluids and stool softeners

Nutritional Consequences

Iron deficiency anemia B12 deficiency Folate deficiency Calcium and Vitamin D deficiency

Not seen with purely restrictive surgeries

Iron deficiency and anemia

Common following RYGB As high as 49 of patients Multifactorial cause

Low gastric acid levels prohibit iron cleavage from food Absorption inhibited because no nutrient exposure to duodenum or

proximal jejunum Decrease in iron-rich food consumption due to intolerance

Treat with oral supplementation of ferrous sulfate or ferrous gluconate

Vitamin B12 deficiency

Up to 70 of patients Lack of hydrochloric acid and pepsin in stomach

Prevents B12 cleavage from food Affects secretion of intrinsic factor thus B12 absorption

Intolerance to meat and milk Oral supplementation usually adequate otherwise IM injections used

Folate Deficiency

40 of gastric bypass patients Complete absorption requires B12 Absorption dependent on HCl and upper 13 stomach Deficiency generally caused by decreased consumption Oral supplementation

Vitamin D and Calcium Deficiency

Vitamin D deficiency is common among obese people Calcium absorption decreased because duodenum is

bypassed Intolerance to dairy foods high in calcium Vitamin D is required for Ca++ absorption Prolonged deficiencies lead to

Bone resorption osteomalacia osteoporosis Treat with calcium citrate supplementation and 2 weekly

doses of Vitamin D

Nutritional Implications of Various Bariatric Surgeries(34)

bull RYGB Malabsorption of Vit B12 Vit B1 (thiamin) Vit D Vit K Folate Iron Calcium

bull LAGB Folic Acid deficiency

bull BPD and BPDDS Vit A D E and K deficiency Protein-Calorie Malnutrition Malabsorption of

Calcium Zinc Selenium Sodium Potassium Chloride Phosphorus Magnesium

Recommended Daily Supplements(4)

Multivitamin with iron (prenatal vitamin will have adeq amount of folic acid)

Calcium (citrate) with vitamin D (1200-1500 mg calcium with 800-1000 IU vitamin D)

Oral vitamin B12 (500-1000 mcg) Iron (65 mgday in elemental form)

Vitamin C (to increase absorption of Iron) Thiamin (10 mgday)

Diet Recommendations(3)

Reduce food volume Chew food very well Slow pace of eating No liquids with meals Encourage fruits and vegetables as diet progresses Include high protein foods (at least 60gday) may need protein

supplements

Diet Progression Gastric Bypass

Stage 1 Clear liquids and protein supplement (1 week)

Stage 2No concentrated sweets low fat puree diet ( 3 weeks)

Stage 3 Regular texture weight reduction diet

Diet Progression Lap - Band

Stage 1 Clear liquids and protein supplement ( 2 weeks)

Stage 2 No concentrated sweets low fat puree diet (2weeks)

Stage 3 Regular texture weight reduction diet

Stage 1

Only clear liquids allowed Avoid sweetened beverages Sip very slowly No straws Avoid caffeinated carbonated and alcoholic beverages STOP drinking if you feel fullness pain or discomfort

Protein supplements

Begin the day after you go home from Hospital

Minimum protein target 70gmsday

May use powder or pre-mixed liquid forms (Whey protein is preferred)

Protein pills may not be used

Vitamin and Mineral Supplements

Gastric bypass patients In addition to eating much less food gastric bypass patients will also

absorb vitamins and minerals differently after surgery They will require daily multivitamin calcium and iron

supplementation for the rest of your life

Vitamin and Mineral Supplements

Lap-Bandreg patients

Require a multivitamin with minerals daily

It may be necessary to take additional vitamins and minerals eg calcium iron folateB1 B12These will be prescribed as needed

Stage 2 dietPUREE

Puree diet

Regular scheduled meals Avoid meal skipping Plan meals in advance Eat Slowly Eat protein foods first Moisten meats Use liquid protein as supplement not as meal replacement

Measure 2 oz portions at each meal eating when full Separate liquids and solids No bread rice or pasta Avoid added sugars and high fat

foods VARIETY

DVT consideration Morbid obesity is a major independent risk factor for sudden death from

acute postoperative pulmonary embolism Subcutaneous heparin 5000 IU administered before surgery and repeated every 8 to 12

hours until the patient is fully mobile reduces the risk of DVT LMWH can also be used

Preoperative prophylactic placement of an inferior vena cava filter should be considered in venous stasis disease BMI ge60 truncal obesity and OSA

What Are the Risks

MAJOR RISKS Death (1 of patients die within 30 days) Severe malnutrition (anemia PEM osteomalacia) Peritonitis (from leakage or ruptures at staple sites)

or other infection Obstructions caused by scar tissue in the stomach or

bowels

MINOR RISKS Dumping Syndrome (unpleasant but not harmful) Diarrhea and malodorous gas production Lactose intolerance Hair loss (short-term post-surgery) May have to eventually undergo surgical revision Pain post-surgery

History of Bariatric Surgery

Obesity surgery is not a new discipline The earliest Bariatric procedure performed was in 1954 at Minnesota The procedure

was Jejuno-ileal bypass In 1966Gastric Bypass was introduced as a surgical procedure for weight loss at the

University of Iowa In 1977Griffen reported the first Roux-en-Y Gastric Bypass In 1980surgeons with a more conservative approach developed the Vertical Banded

Gastroplasty Other procedures with longer intestinal segment bypass were also introduced such as

Biliopancreatic Diversions These complex procedures are recommended in super-obese patients ie BMIgt60

How does surgery work

RESTRICTIVE - RESTRICT AMOUNT OF FOOD INGESTED Decreases appetitehunger

Early satiety Behavior modification Gastric Banding (Lap Band)

Roux-en Y Gastric bypass (RYGB) Sleeve Gastrectomy

MALABSORPTIVE- LIMITS DIGESTION AND ABSORPTION Decreases length of intestine exposed to digested food

25 of fat is absorbed Behavior modification

Biliopancreatic Diversion Duodenal Switch (BPDDS)

ALL OPERATIONS CAN BE PERFORMED OPEN OR LAPAROSCOPICALLY

Laparoscopic vs Open

OPEN uarr post op pain Longer hospitalizations uarr wound complications

Infection Hernias Seromas

Return to work in 4-8 weeks

LAPAROSCOPIC darr post op pain Early mobility darr Wound complications 2-3 day hospital stay Return to work in 1-3 weeks

1 Nguyen NT et al Accelerated growth of bariatric surgery with the introduction of minimally invasive surgery Arch Surg 20051401198-202

Procedures that are solely restrictive by creating a small gastric pouch of volume 15 to 30 cc amp a degree of outlet obstruction leading to delayed gastric emptying The goal is to reduce oral intake by limiting gastric volume produce early satiety and leave the alimentary canal in continuity minimizing the risks of metabolic complications

1VERTICAL BANDED GASTROPLASTY

2ADJUSTABLE GASTRIC BANDING (LAGB )

3 SLEEVE GASTRECTOMY

4GASTRIC PLICATION

5 INTRA GASTRIC BALLOON (GASTRIC BALLOON)

RESTRICTIVE PROCEDURES

Malabsorption is achieved by creating a short gut syndrome andor by accomplishing distal mixing of bile and pancreatic juice with ingested nutrients thereby reducing absorption Some purely malabsorptive operations are no longer recommended due to their potential hazard to cause serious nutritional deficiencies

1 BILIOPANCREATIC DIVERSION2 THE JEJUNAL-ILEAL BYPASS3 ENDOLUMINAL SLEEVE

MALABSORPTIVE PROCEDURES

MIXED PROCEDURES

1GASTRIC BYPASS ROUX-EN-Y ( RYGBP)

2SLEEVE GASTRECTOMY WITH DUODENAL SWITCH

3IMPLANTABLE 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

The stomach is partitioned along its axis with a non-

adjustable poly-urethane band and with linear amp 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 was practiced in 1980

Vertical Banded Gastroplasty (VBG)

ADJUSTABLE GASTRIC BANDING (LAP BAND SURGERY LAGB)

Restrictive Procedure The procedure was first performed by Cadiere in 1992 but was made popular by Belachew and Legrand in 1993 An inflatable silicone BAND is placed around the top portion of the stomach to form a small stomach pouch amp sewed

This band is connected to a tube that leads to a port above the abdominal muscles placed below the skin (FILL ndash PORT)

During follow up visits we inject or remove saline solution to make the band tighter or looser

Adjustable Gastric Band

bull 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

How does the Band work

Surgery Factors Restriction of meal size Decreased appetite

Patient Factors Decreased calorie intake Increased calorie expenditure

LAP-BAND Adjustability

Unfilled Band Filled Band

Adjustments are made in the office

Complications of Gastric Lap-Band

bull Perforation of Stomachbull Slippagebull Gastric Erosion(much less after Pars flaccida technique) bull Dilated Esophagusbull Tubing access port problemsbull Mal positioningbull Abdominal Painbull Heartburnbull Vomitingbull Inability to Adjust the Bandbull Failure to Lose Weightbull Infection of Systembull Fatigue or malfunction

Advantages

No intestinal surgery No staplingcutting of stomach No nutritional risks Adjustable Reversible Safe

Foreign body Frequent follow-up visits Needs more commitment Easy to cheat

Disadvantages

Comparison of Adjustable Gastric Banding and Vertical Banded Gastroplasty

Laparoscopic adjustable gastric banding Reversible Adjustable Simpler to perform laparoscopically Sustained weight loss of gt50 EBW gt5

years following surgery Complications Gastric prolapse band

erosion rarely gastric perforation and access port complications

Vertical banded gastroplasty Irreversible Non adjustable Technically difficult by laparoscopy Weight loss of 25-50 EBW and weight gain

after 2-3 years Complications suture line disruption gastric

leak weight gain

>

>

Originally used as the first-stage operation for a proposed biliopancreatic diversion with duodenal switch in high-risk patients

The sleeve gastrectomy has caught on as a primary obesity treatment as surgeons are reporting weight loss of 55 of excess body weight past 5 years in some patients

The sleeve gastrectomy is also known as the greater curvature gastrectomy vertical or longitudinal gastrectomy or Pylorus preserving lsquogastric tube creationrsquo

Rapid and less traumatic operation Good resolution of co-morbidities and good weight loss

A further second surgical step is then easily feasible if necessary

SLEEVE GASTRECTOMY

SLEEVE GASTRECTOMY

A sleeve gastrectomy involves resection of

approximately 80 of the greater curvature

side of the stomach

Smaller tubular gastric ldquosleeverdquo created

along the lesser curve that is based on the

lesser curvature blood supply

Ideal approximate capacity of the stomach

after the procedure is about 30- 60 ml pouch

1MECHANICAL RESTRICTION by reducing the volume of the stomach and impairing stomach mobility Also called lsquoFood limitingrsquo operation

2HORMONAL MODIFICATION by removing a great part of the Ghrelin (Hunger Hormone) production tissue

(Ghrelin is a 28 amino-acid-peptide secreted by the oxyntic glands of the gastric fungus It is a potent orexigenic (appetite-stimulating) peptide mediated by the activation of its receptors in the hypothalamus or pituitary area)

The gastric fundus contains 10 to 20 times more ghrelin per one gram of tissue than the duodenum In the SG resection of the fundus removes the major portion of ghrelin release therefore appetite decreases

The sleeve gastrectomy (SG) induces weight loss by 2 mechanisms

>

Intragastric balloon involves placing a deflated balloon into the stomach and then filling it to decrease the amount of gastric space

The balloon can be left in the stomach for a maximum of 6 months and results in an average weight loss of 5ndash9 BMI over half a year

Done endoscopically

The intragastric balloon may be used prior to another bariatric surgery as a step-down procedure

INTRA GASTRIC BALLOON

>

>

The EndoBarrier gastrointestinal liner mimics the effects of gastric bypass surgery

Itrsquos designed to work by inserting a flexible

tube-like barrier into the duodenum amp 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

ENDO BARRIER LINER SYSTEM

B MAL- ABSORPTIVE PROCEDURES

Malabsorptive surgeries rearrange andor remove part of digestive system which then limits the amount of calories and nutrients that body can absorb Treatment with a large malabsorptive component results in the most weight loss but tend to have slightly higher complication rates

1JEJUNAL ILEAL BYPASS ndash no longer performed for high complication rates

2ILEAL TRANSPOSITION- New malabsoptive procedure on trial for treatment of DM type 2 and metabolic disorders

C COMBINATION PROCEDURES RESTRICTIVE + MALABSORBTIVE

1LAP GASTRIC BYPASS ndash ROUX-EN- Y ndash more malabsorption than the restrictive

2MINI- GASTRIC BYPASS- mainly restrictive

3DUODENAL SWITCH ndash the sleeve stomach is the restrictive portion ampthe intestinal bypass (duodenal switch) is the malabsorptive component

When surgery combines both restrictive and malabsorptive techniques it is know as a ldquocombinationrdquo procedure Most types of bariatric surgery carry at least a small element of both components but the following surgeries achieve a notable portion of weight loss from eachhellip

1 LAP GASTRIC BYPASS LGB

The Roux-en-Y gastric bypass(known simply as the LRYGBP) is the most commonly performed procedure

It primarily causesweight loss by restricting thefood intake however there ismore amount of mal absorption that occurs with this operation

GASTRIC BYPASS LRYGBP

bullThe stomach is stapled into2 pieces one small and one large The small piece becomes the ldquonewrdquo stomach pouch

bull The larger portion of the stomach stays in place however will lie dormant for the remainder of the patientrsquos life

GASTRIC BYPASS LGB

bull The small intestine (the jejunum) is divided using a surgical staplerApprox 50-70 cm from the DJ Junction

GASTRIC BYPASS LGB

Y- LIMB BP LIMB

bull The end of the Roux limb is then attached to the newly formed stomach pouch which carries food to the distal intestine

bull The Roux loop is completed by forming a jejunostomy

bull The Y limb or BPD limb carries digestive juices from the pancreas gall bladder liver and duodenum to the intestines

bull The food and the digestive juices mix where the Roux limb and Y limb meet much below say 100-150 cm from DJ

Roux limb or alimentary limb

100-150 cm

How Does the Roux-en-Y Work

Surgery factors restriction of meal size ldquodumping syndromerdquo some malabsorption decreased appetite

Patient factors calorie intake calorie expenditure

bull Most commonly performedbull Most reliable operation for long term weight lossbull Long term weight loss averages 60 to 75 percent of EBWbull Malnutrition is unusualbull Substantial improvement amp resolution in many co-morbid

obesity conditions

ADVANTAGES OF RYGBP

1 Not reversible

2 Mortality 05- 1

3 Perioperative complications 5-10

4 Stricture of gastrojejunostomy-10 (long term)

5 Long term risk of protein amp vitamin deficiency and marginal ulceration of GJA

6Long term risk of intestinal obstruction ndash 2

LAPAROSCOPIC GASTRIC BYPASSCOMPLICATIONS

Biliopancreatic Diversion (BPD)

Primarily malabsorptive but restrictive component also

First Terminal ileum is measured to a length of 50 cms marked with suture

The alimentary tract beyond the proximal part of stomach is rearranged to

include only distal 200 cm of ileum including common channel

Common channel-Distal 50 cm of terminal ileum for absorption of fat and

protein

The proximal end of ileum anastomosed to proximal end of stomach after

performing distal hemigastrectomy

Biliopancreatic Diversion with Duodenal Switch

Modification to lessen high incidence of vit b12 deficiency anastomotic stricture at gastrojejunal anastomosis

This procedure involves a sleeve gastrectomy that is then diverted at the duodenum into the ileum at a point measured proximally from the ileocecal valve (usually 250 cm)

The distal duodenum and jejunum the biliopancreatic limb are then anastomosed to the ileum at a point measured proximally from the ileocecal valve (usually 100 cm)

Common channel is 100cm Entire alimentary tract is 250 cm This is the most aggressive bypass procedure commonly offered today Major difference-Sleeve gastrectomy instead of distal hemigastrectomy

bull Most women regained normal menstrual function and most had documented

spontaneous ovulation

bull Significant improvement in hirsutism androgen profiles and about a 50 reduction in

HOMA-IR

bull Follow up for more than 2 years showed that all women resumed normal menstrual

cycles HbA1C decreased from 82 to 51 in lt 3 months

bull 78 saw improvement in metabolic syndrome amp 48 showed improvement in PCOS

2 ROLE OF BARIATRIC SURGERY IN PCOS PATIENTS

bull Decrease menstrual irregularities bull PCOS women have less hyper androgenism

bull Sex hormone binding globulin increases bull LH and FSH levels have been reported to increase

bull Ovulatory function measured by luteal LH and Progesterone secretion improved bull Leptin levels decrease reflecting improved reproductive metabolic status

bull Subclinical hypothyroidism significantly reduced

THE SAFE TIMING OF PREGNANCYoptimal or minimal time gt12 months after bariatric surgery before becoming pregnant in order to allow the rapid weight loss and metabolic changes to subside

4 BARIATRIC SURGERY IN REPRODUCTIVE WOMEN

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)

The foregut hypothesis theory ndash 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

Effect of Bariatric Surgery on Diabetes Mellitus

Combined Gastric Restriction amp Malabsorption

Operative Risks (vs cholecystectomy)

Perioperative Mortality 1-2 vs 02-08 Early Complications 10 vs 29Late Complications 20 vs 1-2

LimitationsWidening of (unbanded) gastrojejunostomyExpansion of gastric pouch 25 with nearly 100 weight regainAdaptation of limb that receives the food

SUMMARY OF ALL TYPES OF SURGERY

bull LRYGBP ndash worlds best procedure 60-70 WL dumping syndrome malnutrition

bull LAGB- low complications varying range of wt loss frequent post-op visits ( 10)

bull DSBPD- more wt loss high complications good for high BMI gt 50 malabsorption +

bull VBG(vertical band gastroplasty) ndash longest available results good wt loss improved co-morbidities right for some ptsrisks too high to justify rewards

bull SG- needs long term research 1st step procedure low risks higher wt loss lesser complications pouch could Stretch over time long staple line could cause problems in future frequency is accelerating because of technical ease 1st stage procedure before bypass

Post-surgical Complications

Anastomosis leaks or staple line leaks Pulmonary Embolism or DVT Cholelithiasis Stomal ulceration Dumping syndrome Constipation

Anastamosis Leaks

Up to 7-10 days after surgery Most common at gastrojejunostomy enteroenterostomy Roux

limb stump staple line Can lead to peritonitis sepsis possible death Presentation

Tachycardia tachypnea Fever Ab painback pain Pelvic pressure or rebound tenderness

Anastamosis Leaks

Order Gastrograffin upper GI series Subclinical cases

Bowel rest Parenteral nutrition IV antibiotic if H pylori

Clinically suspect leak Laparoscopic evaluation and leak repair

Failure to evaluate is the most common cause of preventable major long-term disability or death in bariatric surgical patients

Pulmonary Embolism

Sudden cause of death up to one month after surgery 20-30 mortality rate High risk may have vena cava filter placement prior to surgery Prophylaxis with compression stockings and LMWH Early ambulation imperitive

Pulmonary Embolism

Presentation Profound hypoxia Hypotension Signs of sepsis

Immediate spiral chest CT Abdominal exploration if too large for machine No pathology start anticoagulation Too largehelliphellipNO SURGERY

Cholelithiasis

Up to 36 of patients within 6 months post-op Bile stasis leads to increased sludge and gallstones Prophylactic cholecystectomy prior to surgery if

evidence of existing sludge or stones Prevent post-operative disease with concurrent bariatric

surgery and cholecystectomy Prophylactic use of urosidol

Expensive and unpalatable

Stomal Ulceration

12-15 within 2-4 mos Post-surgery Etiology

Overabundant acid in pouch leads to excessive acid passing through stoma

Pouch tension and staple line breakdown NSAID use

Presentation Dyspepsia vomiting Epigastric or retrosternal pain

Stomal Ulceration

Treatment PPI carafate Antibiotics if H Pylori Avoid NSAIDS alcohol smoking

If no response to treatment Endoscopy Back to surgery for pouch revision or staple line repair

Dumping Syndrome

More than 15 patients Hypotention Tachycardia Lightheadedness syncope Flushing Abdominal cramping and diarrhea Nausea and vomiting

Dumping Syndrome

Occurs with high dose simple sugar ingestion Sugar in small intestine causes osmotic overload and fluid

shift from blood to intestine Increased intestinal volume leads to watery diarrhea Decreased blood volume leads to systemic changes Patient education

Eat slowly Avoid drinking before during and not until 30 minutes after meals

Constipation

Most common complaint Causes

Dehydration and decreased fluid intake post-operatively Increased metabolic water needs Calcium and iron supplement use following surgery

Treat with increased fluids and stool softeners

Nutritional Consequences

Iron deficiency anemia B12 deficiency Folate deficiency Calcium and Vitamin D deficiency

Not seen with purely restrictive surgeries

Iron deficiency and anemia

Common following RYGB As high as 49 of patients Multifactorial cause

Low gastric acid levels prohibit iron cleavage from food Absorption inhibited because no nutrient exposure to duodenum or

proximal jejunum Decrease in iron-rich food consumption due to intolerance

Treat with oral supplementation of ferrous sulfate or ferrous gluconate

Vitamin B12 deficiency

Up to 70 of patients Lack of hydrochloric acid and pepsin in stomach

Prevents B12 cleavage from food Affects secretion of intrinsic factor thus B12 absorption

Intolerance to meat and milk Oral supplementation usually adequate otherwise IM injections used

Folate Deficiency

40 of gastric bypass patients Complete absorption requires B12 Absorption dependent on HCl and upper 13 stomach Deficiency generally caused by decreased consumption Oral supplementation

Vitamin D and Calcium Deficiency

Vitamin D deficiency is common among obese people Calcium absorption decreased because duodenum is

bypassed Intolerance to dairy foods high in calcium Vitamin D is required for Ca++ absorption Prolonged deficiencies lead to

Bone resorption osteomalacia osteoporosis Treat with calcium citrate supplementation and 2 weekly

doses of Vitamin D

Nutritional Implications of Various Bariatric Surgeries(34)

bull RYGB Malabsorption of Vit B12 Vit B1 (thiamin) Vit D Vit K Folate Iron Calcium

bull LAGB Folic Acid deficiency

bull BPD and BPDDS Vit A D E and K deficiency Protein-Calorie Malnutrition Malabsorption of

Calcium Zinc Selenium Sodium Potassium Chloride Phosphorus Magnesium

Recommended Daily Supplements(4)

Multivitamin with iron (prenatal vitamin will have adeq amount of folic acid)

Calcium (citrate) with vitamin D (1200-1500 mg calcium with 800-1000 IU vitamin D)

Oral vitamin B12 (500-1000 mcg) Iron (65 mgday in elemental form)

Vitamin C (to increase absorption of Iron) Thiamin (10 mgday)

Diet Recommendations(3)

Reduce food volume Chew food very well Slow pace of eating No liquids with meals Encourage fruits and vegetables as diet progresses Include high protein foods (at least 60gday) may need protein

supplements

Diet Progression Gastric Bypass

Stage 1 Clear liquids and protein supplement (1 week)

Stage 2No concentrated sweets low fat puree diet ( 3 weeks)

Stage 3 Regular texture weight reduction diet

Diet Progression Lap - Band

Stage 1 Clear liquids and protein supplement ( 2 weeks)

Stage 2 No concentrated sweets low fat puree diet (2weeks)

Stage 3 Regular texture weight reduction diet

Stage 1

Only clear liquids allowed Avoid sweetened beverages Sip very slowly No straws Avoid caffeinated carbonated and alcoholic beverages STOP drinking if you feel fullness pain or discomfort

Protein supplements

Begin the day after you go home from Hospital

Minimum protein target 70gmsday

May use powder or pre-mixed liquid forms (Whey protein is preferred)

Protein pills may not be used

Vitamin and Mineral Supplements

Gastric bypass patients In addition to eating much less food gastric bypass patients will also

absorb vitamins and minerals differently after surgery They will require daily multivitamin calcium and iron

supplementation for the rest of your life

Vitamin and Mineral Supplements

Lap-Bandreg patients

Require a multivitamin with minerals daily

It may be necessary to take additional vitamins and minerals eg calcium iron folateB1 B12These will be prescribed as needed

Stage 2 dietPUREE

Puree diet

Regular scheduled meals Avoid meal skipping Plan meals in advance Eat Slowly Eat protein foods first Moisten meats Use liquid protein as supplement not as meal replacement

Measure 2 oz portions at each meal eating when full Separate liquids and solids No bread rice or pasta Avoid added sugars and high fat

foods VARIETY

What Are the Risks

MAJOR RISKS Death (1 of patients die within 30 days) Severe malnutrition (anemia PEM osteomalacia) Peritonitis (from leakage or ruptures at staple sites)

or other infection Obstructions caused by scar tissue in the stomach or

bowels

MINOR RISKS Dumping Syndrome (unpleasant but not harmful) Diarrhea and malodorous gas production Lactose intolerance Hair loss (short-term post-surgery) May have to eventually undergo surgical revision Pain post-surgery

History of Bariatric Surgery

Obesity surgery is not a new discipline The earliest Bariatric procedure performed was in 1954 at Minnesota The procedure

was Jejuno-ileal bypass In 1966Gastric Bypass was introduced as a surgical procedure for weight loss at the

University of Iowa In 1977Griffen reported the first Roux-en-Y Gastric Bypass In 1980surgeons with a more conservative approach developed the Vertical Banded

Gastroplasty Other procedures with longer intestinal segment bypass were also introduced such as

Biliopancreatic Diversions These complex procedures are recommended in super-obese patients ie BMIgt60

How does surgery work

RESTRICTIVE - RESTRICT AMOUNT OF FOOD INGESTED Decreases appetitehunger

Early satiety Behavior modification Gastric Banding (Lap Band)

Roux-en Y Gastric bypass (RYGB) Sleeve Gastrectomy

MALABSORPTIVE- LIMITS DIGESTION AND ABSORPTION Decreases length of intestine exposed to digested food

25 of fat is absorbed Behavior modification

Biliopancreatic Diversion Duodenal Switch (BPDDS)

ALL OPERATIONS CAN BE PERFORMED OPEN OR LAPAROSCOPICALLY

Laparoscopic vs Open

OPEN uarr post op pain Longer hospitalizations uarr wound complications

Infection Hernias Seromas

Return to work in 4-8 weeks

LAPAROSCOPIC darr post op pain Early mobility darr Wound complications 2-3 day hospital stay Return to work in 1-3 weeks

1 Nguyen NT et al Accelerated growth of bariatric surgery with the introduction of minimally invasive surgery Arch Surg 20051401198-202

Procedures that are solely restrictive by creating a small gastric pouch of volume 15 to 30 cc amp a degree of outlet obstruction leading to delayed gastric emptying The goal is to reduce oral intake by limiting gastric volume produce early satiety and leave the alimentary canal in continuity minimizing the risks of metabolic complications

1VERTICAL BANDED GASTROPLASTY

2ADJUSTABLE GASTRIC BANDING (LAGB )

3 SLEEVE GASTRECTOMY

4GASTRIC PLICATION

5 INTRA GASTRIC BALLOON (GASTRIC BALLOON)

RESTRICTIVE PROCEDURES

Malabsorption is achieved by creating a short gut syndrome andor by accomplishing distal mixing of bile and pancreatic juice with ingested nutrients thereby reducing absorption Some purely malabsorptive operations are no longer recommended due to their potential hazard to cause serious nutritional deficiencies

1 BILIOPANCREATIC DIVERSION2 THE JEJUNAL-ILEAL BYPASS3 ENDOLUMINAL SLEEVE

MALABSORPTIVE PROCEDURES

MIXED PROCEDURES

1GASTRIC BYPASS ROUX-EN-Y ( RYGBP)

2SLEEVE GASTRECTOMY WITH DUODENAL SWITCH

3IMPLANTABLE 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

The stomach is partitioned along its axis with a non-

adjustable poly-urethane band and with linear amp 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 was practiced in 1980

Vertical Banded Gastroplasty (VBG)

ADJUSTABLE GASTRIC BANDING (LAP BAND SURGERY LAGB)

Restrictive Procedure The procedure was first performed by Cadiere in 1992 but was made popular by Belachew and Legrand in 1993 An inflatable silicone BAND is placed around the top portion of the stomach to form a small stomach pouch amp sewed

This band is connected to a tube that leads to a port above the abdominal muscles placed below the skin (FILL ndash PORT)

During follow up visits we inject or remove saline solution to make the band tighter or looser

Adjustable Gastric Band

bull 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

How does the Band work

Surgery Factors Restriction of meal size Decreased appetite

Patient Factors Decreased calorie intake Increased calorie expenditure

LAP-BAND Adjustability

Unfilled Band Filled Band

Adjustments are made in the office

Complications of Gastric Lap-Band

bull Perforation of Stomachbull Slippagebull Gastric Erosion(much less after Pars flaccida technique) bull Dilated Esophagusbull Tubing access port problemsbull Mal positioningbull Abdominal Painbull Heartburnbull Vomitingbull Inability to Adjust the Bandbull Failure to Lose Weightbull Infection of Systembull Fatigue or malfunction

Advantages

No intestinal surgery No staplingcutting of stomach No nutritional risks Adjustable Reversible Safe

Foreign body Frequent follow-up visits Needs more commitment Easy to cheat

Disadvantages

Comparison of Adjustable Gastric Banding and Vertical Banded Gastroplasty

Laparoscopic adjustable gastric banding Reversible Adjustable Simpler to perform laparoscopically Sustained weight loss of gt50 EBW gt5

years following surgery Complications Gastric prolapse band

erosion rarely gastric perforation and access port complications

Vertical banded gastroplasty Irreversible Non adjustable Technically difficult by laparoscopy Weight loss of 25-50 EBW and weight gain

after 2-3 years Complications suture line disruption gastric

leak weight gain

>

>

Originally used as the first-stage operation for a proposed biliopancreatic diversion with duodenal switch in high-risk patients

The sleeve gastrectomy has caught on as a primary obesity treatment as surgeons are reporting weight loss of 55 of excess body weight past 5 years in some patients

The sleeve gastrectomy is also known as the greater curvature gastrectomy vertical or longitudinal gastrectomy or Pylorus preserving lsquogastric tube creationrsquo

Rapid and less traumatic operation Good resolution of co-morbidities and good weight loss

A further second surgical step is then easily feasible if necessary

SLEEVE GASTRECTOMY

SLEEVE GASTRECTOMY

A sleeve gastrectomy involves resection of

approximately 80 of the greater curvature

side of the stomach

Smaller tubular gastric ldquosleeverdquo created

along the lesser curve that is based on the

lesser curvature blood supply

Ideal approximate capacity of the stomach

after the procedure is about 30- 60 ml pouch

1MECHANICAL RESTRICTION by reducing the volume of the stomach and impairing stomach mobility Also called lsquoFood limitingrsquo operation

2HORMONAL MODIFICATION by removing a great part of the Ghrelin (Hunger Hormone) production tissue

(Ghrelin is a 28 amino-acid-peptide secreted by the oxyntic glands of the gastric fungus It is a potent orexigenic (appetite-stimulating) peptide mediated by the activation of its receptors in the hypothalamus or pituitary area)

The gastric fundus contains 10 to 20 times more ghrelin per one gram of tissue than the duodenum In the SG resection of the fundus removes the major portion of ghrelin release therefore appetite decreases

The sleeve gastrectomy (SG) induces weight loss by 2 mechanisms

>

Intragastric balloon involves placing a deflated balloon into the stomach and then filling it to decrease the amount of gastric space

The balloon can be left in the stomach for a maximum of 6 months and results in an average weight loss of 5ndash9 BMI over half a year

Done endoscopically

The intragastric balloon may be used prior to another bariatric surgery as a step-down procedure

INTRA GASTRIC BALLOON

>

>

The EndoBarrier gastrointestinal liner mimics the effects of gastric bypass surgery

Itrsquos designed to work by inserting a flexible

tube-like barrier into the duodenum amp 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

ENDO BARRIER LINER SYSTEM

B MAL- ABSORPTIVE PROCEDURES

Malabsorptive surgeries rearrange andor remove part of digestive system which then limits the amount of calories and nutrients that body can absorb Treatment with a large malabsorptive component results in the most weight loss but tend to have slightly higher complication rates

1JEJUNAL ILEAL BYPASS ndash no longer performed for high complication rates

2ILEAL TRANSPOSITION- New malabsoptive procedure on trial for treatment of DM type 2 and metabolic disorders

C COMBINATION PROCEDURES RESTRICTIVE + MALABSORBTIVE

1LAP GASTRIC BYPASS ndash ROUX-EN- Y ndash more malabsorption than the restrictive

2MINI- GASTRIC BYPASS- mainly restrictive

3DUODENAL SWITCH ndash the sleeve stomach is the restrictive portion ampthe intestinal bypass (duodenal switch) is the malabsorptive component

When surgery combines both restrictive and malabsorptive techniques it is know as a ldquocombinationrdquo procedure Most types of bariatric surgery carry at least a small element of both components but the following surgeries achieve a notable portion of weight loss from eachhellip

1 LAP GASTRIC BYPASS LGB

The Roux-en-Y gastric bypass(known simply as the LRYGBP) is the most commonly performed procedure

It primarily causesweight loss by restricting thefood intake however there ismore amount of mal absorption that occurs with this operation

GASTRIC BYPASS LRYGBP

bullThe stomach is stapled into2 pieces one small and one large The small piece becomes the ldquonewrdquo stomach pouch

bull The larger portion of the stomach stays in place however will lie dormant for the remainder of the patientrsquos life

GASTRIC BYPASS LGB

bull The small intestine (the jejunum) is divided using a surgical staplerApprox 50-70 cm from the DJ Junction

GASTRIC BYPASS LGB

Y- LIMB BP LIMB

bull The end of the Roux limb is then attached to the newly formed stomach pouch which carries food to the distal intestine

bull The Roux loop is completed by forming a jejunostomy

bull The Y limb or BPD limb carries digestive juices from the pancreas gall bladder liver and duodenum to the intestines

bull The food and the digestive juices mix where the Roux limb and Y limb meet much below say 100-150 cm from DJ

Roux limb or alimentary limb

100-150 cm

How Does the Roux-en-Y Work

Surgery factors restriction of meal size ldquodumping syndromerdquo some malabsorption decreased appetite

Patient factors calorie intake calorie expenditure

bull Most commonly performedbull Most reliable operation for long term weight lossbull Long term weight loss averages 60 to 75 percent of EBWbull Malnutrition is unusualbull Substantial improvement amp resolution in many co-morbid

obesity conditions

ADVANTAGES OF RYGBP

1 Not reversible

2 Mortality 05- 1

3 Perioperative complications 5-10

4 Stricture of gastrojejunostomy-10 (long term)

5 Long term risk of protein amp vitamin deficiency and marginal ulceration of GJA

6Long term risk of intestinal obstruction ndash 2

LAPAROSCOPIC GASTRIC BYPASSCOMPLICATIONS

Biliopancreatic Diversion (BPD)

Primarily malabsorptive but restrictive component also

First Terminal ileum is measured to a length of 50 cms marked with suture

The alimentary tract beyond the proximal part of stomach is rearranged to

include only distal 200 cm of ileum including common channel

Common channel-Distal 50 cm of terminal ileum for absorption of fat and

protein

The proximal end of ileum anastomosed to proximal end of stomach after

performing distal hemigastrectomy

Biliopancreatic Diversion with Duodenal Switch

Modification to lessen high incidence of vit b12 deficiency anastomotic stricture at gastrojejunal anastomosis

This procedure involves a sleeve gastrectomy that is then diverted at the duodenum into the ileum at a point measured proximally from the ileocecal valve (usually 250 cm)

The distal duodenum and jejunum the biliopancreatic limb are then anastomosed to the ileum at a point measured proximally from the ileocecal valve (usually 100 cm)

Common channel is 100cm Entire alimentary tract is 250 cm This is the most aggressive bypass procedure commonly offered today Major difference-Sleeve gastrectomy instead of distal hemigastrectomy

bull Most women regained normal menstrual function and most had documented

spontaneous ovulation

bull Significant improvement in hirsutism androgen profiles and about a 50 reduction in

HOMA-IR

bull Follow up for more than 2 years showed that all women resumed normal menstrual

cycles HbA1C decreased from 82 to 51 in lt 3 months

bull 78 saw improvement in metabolic syndrome amp 48 showed improvement in PCOS

2 ROLE OF BARIATRIC SURGERY IN PCOS PATIENTS

bull Decrease menstrual irregularities bull PCOS women have less hyper androgenism

bull Sex hormone binding globulin increases bull LH and FSH levels have been reported to increase

bull Ovulatory function measured by luteal LH and Progesterone secretion improved bull Leptin levels decrease reflecting improved reproductive metabolic status

bull Subclinical hypothyroidism significantly reduced

THE SAFE TIMING OF PREGNANCYoptimal or minimal time gt12 months after bariatric surgery before becoming pregnant in order to allow the rapid weight loss and metabolic changes to subside

4 BARIATRIC SURGERY IN REPRODUCTIVE WOMEN

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)

The foregut hypothesis theory ndash 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

Effect of Bariatric Surgery on Diabetes Mellitus

Combined Gastric Restriction amp Malabsorption

Operative Risks (vs cholecystectomy)

Perioperative Mortality 1-2 vs 02-08 Early Complications 10 vs 29Late Complications 20 vs 1-2

LimitationsWidening of (unbanded) gastrojejunostomyExpansion of gastric pouch 25 with nearly 100 weight regainAdaptation of limb that receives the food

SUMMARY OF ALL TYPES OF SURGERY

bull LRYGBP ndash worlds best procedure 60-70 WL dumping syndrome malnutrition

bull LAGB- low complications varying range of wt loss frequent post-op visits ( 10)

bull DSBPD- more wt loss high complications good for high BMI gt 50 malabsorption +

bull VBG(vertical band gastroplasty) ndash longest available results good wt loss improved co-morbidities right for some ptsrisks too high to justify rewards

bull SG- needs long term research 1st step procedure low risks higher wt loss lesser complications pouch could Stretch over time long staple line could cause problems in future frequency is accelerating because of technical ease 1st stage procedure before bypass

Post-surgical Complications

Anastomosis leaks or staple line leaks Pulmonary Embolism or DVT Cholelithiasis Stomal ulceration Dumping syndrome Constipation

Anastamosis Leaks

Up to 7-10 days after surgery Most common at gastrojejunostomy enteroenterostomy Roux

limb stump staple line Can lead to peritonitis sepsis possible death Presentation

Tachycardia tachypnea Fever Ab painback pain Pelvic pressure or rebound tenderness

Anastamosis Leaks

Order Gastrograffin upper GI series Subclinical cases

Bowel rest Parenteral nutrition IV antibiotic if H pylori

Clinically suspect leak Laparoscopic evaluation and leak repair

Failure to evaluate is the most common cause of preventable major long-term disability or death in bariatric surgical patients

Pulmonary Embolism

Sudden cause of death up to one month after surgery 20-30 mortality rate High risk may have vena cava filter placement prior to surgery Prophylaxis with compression stockings and LMWH Early ambulation imperitive

Pulmonary Embolism

Presentation Profound hypoxia Hypotension Signs of sepsis

Immediate spiral chest CT Abdominal exploration if too large for machine No pathology start anticoagulation Too largehelliphellipNO SURGERY

Cholelithiasis

Up to 36 of patients within 6 months post-op Bile stasis leads to increased sludge and gallstones Prophylactic cholecystectomy prior to surgery if

evidence of existing sludge or stones Prevent post-operative disease with concurrent bariatric

surgery and cholecystectomy Prophylactic use of urosidol

Expensive and unpalatable

Stomal Ulceration

12-15 within 2-4 mos Post-surgery Etiology

Overabundant acid in pouch leads to excessive acid passing through stoma

Pouch tension and staple line breakdown NSAID use

Presentation Dyspepsia vomiting Epigastric or retrosternal pain

Stomal Ulceration

Treatment PPI carafate Antibiotics if H Pylori Avoid NSAIDS alcohol smoking

If no response to treatment Endoscopy Back to surgery for pouch revision or staple line repair

Dumping Syndrome

More than 15 patients Hypotention Tachycardia Lightheadedness syncope Flushing Abdominal cramping and diarrhea Nausea and vomiting

Dumping Syndrome

Occurs with high dose simple sugar ingestion Sugar in small intestine causes osmotic overload and fluid

shift from blood to intestine Increased intestinal volume leads to watery diarrhea Decreased blood volume leads to systemic changes Patient education

Eat slowly Avoid drinking before during and not until 30 minutes after meals

Constipation

Most common complaint Causes

Dehydration and decreased fluid intake post-operatively Increased metabolic water needs Calcium and iron supplement use following surgery

Treat with increased fluids and stool softeners

Nutritional Consequences

Iron deficiency anemia B12 deficiency Folate deficiency Calcium and Vitamin D deficiency

Not seen with purely restrictive surgeries

Iron deficiency and anemia

Common following RYGB As high as 49 of patients Multifactorial cause

Low gastric acid levels prohibit iron cleavage from food Absorption inhibited because no nutrient exposure to duodenum or

proximal jejunum Decrease in iron-rich food consumption due to intolerance

Treat with oral supplementation of ferrous sulfate or ferrous gluconate

Vitamin B12 deficiency

Up to 70 of patients Lack of hydrochloric acid and pepsin in stomach

Prevents B12 cleavage from food Affects secretion of intrinsic factor thus B12 absorption

Intolerance to meat and milk Oral supplementation usually adequate otherwise IM injections used

Folate Deficiency

40 of gastric bypass patients Complete absorption requires B12 Absorption dependent on HCl and upper 13 stomach Deficiency generally caused by decreased consumption Oral supplementation

Vitamin D and Calcium Deficiency

Vitamin D deficiency is common among obese people Calcium absorption decreased because duodenum is

bypassed Intolerance to dairy foods high in calcium Vitamin D is required for Ca++ absorption Prolonged deficiencies lead to

Bone resorption osteomalacia osteoporosis Treat with calcium citrate supplementation and 2 weekly

doses of Vitamin D

Nutritional Implications of Various Bariatric Surgeries(34)

bull RYGB Malabsorption of Vit B12 Vit B1 (thiamin) Vit D Vit K Folate Iron Calcium

bull LAGB Folic Acid deficiency

bull BPD and BPDDS Vit A D E and K deficiency Protein-Calorie Malnutrition Malabsorption of

Calcium Zinc Selenium Sodium Potassium Chloride Phosphorus Magnesium

Recommended Daily Supplements(4)

Multivitamin with iron (prenatal vitamin will have adeq amount of folic acid)

Calcium (citrate) with vitamin D (1200-1500 mg calcium with 800-1000 IU vitamin D)

Oral vitamin B12 (500-1000 mcg) Iron (65 mgday in elemental form)

Vitamin C (to increase absorption of Iron) Thiamin (10 mgday)

Diet Recommendations(3)

Reduce food volume Chew food very well Slow pace of eating No liquids with meals Encourage fruits and vegetables as diet progresses Include high protein foods (at least 60gday) may need protein

supplements

Diet Progression Gastric Bypass

Stage 1 Clear liquids and protein supplement (1 week)

Stage 2No concentrated sweets low fat puree diet ( 3 weeks)

Stage 3 Regular texture weight reduction diet

Diet Progression Lap - Band

Stage 1 Clear liquids and protein supplement ( 2 weeks)

Stage 2 No concentrated sweets low fat puree diet (2weeks)

Stage 3 Regular texture weight reduction diet

Stage 1

Only clear liquids allowed Avoid sweetened beverages Sip very slowly No straws Avoid caffeinated carbonated and alcoholic beverages STOP drinking if you feel fullness pain or discomfort

Protein supplements

Begin the day after you go home from Hospital

Minimum protein target 70gmsday

May use powder or pre-mixed liquid forms (Whey protein is preferred)

Protein pills may not be used

Vitamin and Mineral Supplements

Gastric bypass patients In addition to eating much less food gastric bypass patients will also

absorb vitamins and minerals differently after surgery They will require daily multivitamin calcium and iron

supplementation for the rest of your life

Vitamin and Mineral Supplements

Lap-Bandreg patients

Require a multivitamin with minerals daily

It may be necessary to take additional vitamins and minerals eg calcium iron folateB1 B12These will be prescribed as needed

Stage 2 dietPUREE

Puree diet

Regular scheduled meals Avoid meal skipping Plan meals in advance Eat Slowly Eat protein foods first Moisten meats Use liquid protein as supplement not as meal replacement

Measure 2 oz portions at each meal eating when full Separate liquids and solids No bread rice or pasta Avoid added sugars and high fat

foods VARIETY

History of Bariatric Surgery

Obesity surgery is not a new discipline The earliest Bariatric procedure performed was in 1954 at Minnesota The procedure

was Jejuno-ileal bypass In 1966Gastric Bypass was introduced as a surgical procedure for weight loss at the

University of Iowa In 1977Griffen reported the first Roux-en-Y Gastric Bypass In 1980surgeons with a more conservative approach developed the Vertical Banded

Gastroplasty Other procedures with longer intestinal segment bypass were also introduced such as

Biliopancreatic Diversions These complex procedures are recommended in super-obese patients ie BMIgt60

How does surgery work

RESTRICTIVE - RESTRICT AMOUNT OF FOOD INGESTED Decreases appetitehunger

Early satiety Behavior modification Gastric Banding (Lap Band)

Roux-en Y Gastric bypass (RYGB) Sleeve Gastrectomy

MALABSORPTIVE- LIMITS DIGESTION AND ABSORPTION Decreases length of intestine exposed to digested food

25 of fat is absorbed Behavior modification

Biliopancreatic Diversion Duodenal Switch (BPDDS)

ALL OPERATIONS CAN BE PERFORMED OPEN OR LAPAROSCOPICALLY

Laparoscopic vs Open

OPEN uarr post op pain Longer hospitalizations uarr wound complications

Infection Hernias Seromas

Return to work in 4-8 weeks

LAPAROSCOPIC darr post op pain Early mobility darr Wound complications 2-3 day hospital stay Return to work in 1-3 weeks

1 Nguyen NT et al Accelerated growth of bariatric surgery with the introduction of minimally invasive surgery Arch Surg 20051401198-202

Procedures that are solely restrictive by creating a small gastric pouch of volume 15 to 30 cc amp a degree of outlet obstruction leading to delayed gastric emptying The goal is to reduce oral intake by limiting gastric volume produce early satiety and leave the alimentary canal in continuity minimizing the risks of metabolic complications

1VERTICAL BANDED GASTROPLASTY

2ADJUSTABLE GASTRIC BANDING (LAGB )

3 SLEEVE GASTRECTOMY

4GASTRIC PLICATION

5 INTRA GASTRIC BALLOON (GASTRIC BALLOON)

RESTRICTIVE PROCEDURES

Malabsorption is achieved by creating a short gut syndrome andor by accomplishing distal mixing of bile and pancreatic juice with ingested nutrients thereby reducing absorption Some purely malabsorptive operations are no longer recommended due to their potential hazard to cause serious nutritional deficiencies

1 BILIOPANCREATIC DIVERSION2 THE JEJUNAL-ILEAL BYPASS3 ENDOLUMINAL SLEEVE

MALABSORPTIVE PROCEDURES

MIXED PROCEDURES

1GASTRIC BYPASS ROUX-EN-Y ( RYGBP)

2SLEEVE GASTRECTOMY WITH DUODENAL SWITCH

3IMPLANTABLE 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

The stomach is partitioned along its axis with a non-

adjustable poly-urethane band and with linear amp 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 was practiced in 1980

Vertical Banded Gastroplasty (VBG)

ADJUSTABLE GASTRIC BANDING (LAP BAND SURGERY LAGB)

Restrictive Procedure The procedure was first performed by Cadiere in 1992 but was made popular by Belachew and Legrand in 1993 An inflatable silicone BAND is placed around the top portion of the stomach to form a small stomach pouch amp sewed

This band is connected to a tube that leads to a port above the abdominal muscles placed below the skin (FILL ndash PORT)

During follow up visits we inject or remove saline solution to make the band tighter or looser

Adjustable Gastric Band

bull 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

How does the Band work

Surgery Factors Restriction of meal size Decreased appetite

Patient Factors Decreased calorie intake Increased calorie expenditure

LAP-BAND Adjustability

Unfilled Band Filled Band

Adjustments are made in the office

Complications of Gastric Lap-Band

bull Perforation of Stomachbull Slippagebull Gastric Erosion(much less after Pars flaccida technique) bull Dilated Esophagusbull Tubing access port problemsbull Mal positioningbull Abdominal Painbull Heartburnbull Vomitingbull Inability to Adjust the Bandbull Failure to Lose Weightbull Infection of Systembull Fatigue or malfunction

Advantages

No intestinal surgery No staplingcutting of stomach No nutritional risks Adjustable Reversible Safe

Foreign body Frequent follow-up visits Needs more commitment Easy to cheat

Disadvantages

Comparison of Adjustable Gastric Banding and Vertical Banded Gastroplasty

Laparoscopic adjustable gastric banding Reversible Adjustable Simpler to perform laparoscopically Sustained weight loss of gt50 EBW gt5

years following surgery Complications Gastric prolapse band

erosion rarely gastric perforation and access port complications

Vertical banded gastroplasty Irreversible Non adjustable Technically difficult by laparoscopy Weight loss of 25-50 EBW and weight gain

after 2-3 years Complications suture line disruption gastric

leak weight gain

>

>

Originally used as the first-stage operation for a proposed biliopancreatic diversion with duodenal switch in high-risk patients

The sleeve gastrectomy has caught on as a primary obesity treatment as surgeons are reporting weight loss of 55 of excess body weight past 5 years in some patients

The sleeve gastrectomy is also known as the greater curvature gastrectomy vertical or longitudinal gastrectomy or Pylorus preserving lsquogastric tube creationrsquo

Rapid and less traumatic operation Good resolution of co-morbidities and good weight loss

A further second surgical step is then easily feasible if necessary

SLEEVE GASTRECTOMY

SLEEVE GASTRECTOMY

A sleeve gastrectomy involves resection of

approximately 80 of the greater curvature

side of the stomach

Smaller tubular gastric ldquosleeverdquo created

along the lesser curve that is based on the

lesser curvature blood supply

Ideal approximate capacity of the stomach

after the procedure is about 30- 60 ml pouch

1MECHANICAL RESTRICTION by reducing the volume of the stomach and impairing stomach mobility Also called lsquoFood limitingrsquo operation

2HORMONAL MODIFICATION by removing a great part of the Ghrelin (Hunger Hormone) production tissue

(Ghrelin is a 28 amino-acid-peptide secreted by the oxyntic glands of the gastric fungus It is a potent orexigenic (appetite-stimulating) peptide mediated by the activation of its receptors in the hypothalamus or pituitary area)

The gastric fundus contains 10 to 20 times more ghrelin per one gram of tissue than the duodenum In the SG resection of the fundus removes the major portion of ghrelin release therefore appetite decreases

The sleeve gastrectomy (SG) induces weight loss by 2 mechanisms

>

Intragastric balloon involves placing a deflated balloon into the stomach and then filling it to decrease the amount of gastric space

The balloon can be left in the stomach for a maximum of 6 months and results in an average weight loss of 5ndash9 BMI over half a year

Done endoscopically

The intragastric balloon may be used prior to another bariatric surgery as a step-down procedure

INTRA GASTRIC BALLOON

>

>

The EndoBarrier gastrointestinal liner mimics the effects of gastric bypass surgery

Itrsquos designed to work by inserting a flexible

tube-like barrier into the duodenum amp 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

ENDO BARRIER LINER SYSTEM

B MAL- ABSORPTIVE PROCEDURES

Malabsorptive surgeries rearrange andor remove part of digestive system which then limits the amount of calories and nutrients that body can absorb Treatment with a large malabsorptive component results in the most weight loss but tend to have slightly higher complication rates

1JEJUNAL ILEAL BYPASS ndash no longer performed for high complication rates

2ILEAL TRANSPOSITION- New malabsoptive procedure on trial for treatment of DM type 2 and metabolic disorders

C COMBINATION PROCEDURES RESTRICTIVE + MALABSORBTIVE

1LAP GASTRIC BYPASS ndash ROUX-EN- Y ndash more malabsorption than the restrictive

2MINI- GASTRIC BYPASS- mainly restrictive

3DUODENAL SWITCH ndash the sleeve stomach is the restrictive portion ampthe intestinal bypass (duodenal switch) is the malabsorptive component

When surgery combines both restrictive and malabsorptive techniques it is know as a ldquocombinationrdquo procedure Most types of bariatric surgery carry at least a small element of both components but the following surgeries achieve a notable portion of weight loss from eachhellip

1 LAP GASTRIC BYPASS LGB

The Roux-en-Y gastric bypass(known simply as the LRYGBP) is the most commonly performed procedure

It primarily causesweight loss by restricting thefood intake however there ismore amount of mal absorption that occurs with this operation

GASTRIC BYPASS LRYGBP

bullThe stomach is stapled into2 pieces one small and one large The small piece becomes the ldquonewrdquo stomach pouch

bull The larger portion of the stomach stays in place however will lie dormant for the remainder of the patientrsquos life

GASTRIC BYPASS LGB

bull The small intestine (the jejunum) is divided using a surgical staplerApprox 50-70 cm from the DJ Junction

GASTRIC BYPASS LGB

Y- LIMB BP LIMB

bull The end of the Roux limb is then attached to the newly formed stomach pouch which carries food to the distal intestine

bull The Roux loop is completed by forming a jejunostomy

bull The Y limb or BPD limb carries digestive juices from the pancreas gall bladder liver and duodenum to the intestines

bull The food and the digestive juices mix where the Roux limb and Y limb meet much below say 100-150 cm from DJ

Roux limb or alimentary limb

100-150 cm

How Does the Roux-en-Y Work

Surgery factors restriction of meal size ldquodumping syndromerdquo some malabsorption decreased appetite

Patient factors calorie intake calorie expenditure

bull Most commonly performedbull Most reliable operation for long term weight lossbull Long term weight loss averages 60 to 75 percent of EBWbull Malnutrition is unusualbull Substantial improvement amp resolution in many co-morbid

obesity conditions

ADVANTAGES OF RYGBP

1 Not reversible

2 Mortality 05- 1

3 Perioperative complications 5-10

4 Stricture of gastrojejunostomy-10 (long term)

5 Long term risk of protein amp vitamin deficiency and marginal ulceration of GJA

6Long term risk of intestinal obstruction ndash 2

LAPAROSCOPIC GASTRIC BYPASSCOMPLICATIONS

Biliopancreatic Diversion (BPD)

Primarily malabsorptive but restrictive component also

First Terminal ileum is measured to a length of 50 cms marked with suture

The alimentary tract beyond the proximal part of stomach is rearranged to

include only distal 200 cm of ileum including common channel

Common channel-Distal 50 cm of terminal ileum for absorption of fat and

protein

The proximal end of ileum anastomosed to proximal end of stomach after

performing distal hemigastrectomy

Biliopancreatic Diversion with Duodenal Switch

Modification to lessen high incidence of vit b12 deficiency anastomotic stricture at gastrojejunal anastomosis

This procedure involves a sleeve gastrectomy that is then diverted at the duodenum into the ileum at a point measured proximally from the ileocecal valve (usually 250 cm)

The distal duodenum and jejunum the biliopancreatic limb are then anastomosed to the ileum at a point measured proximally from the ileocecal valve (usually 100 cm)

Common channel is 100cm Entire alimentary tract is 250 cm This is the most aggressive bypass procedure commonly offered today Major difference-Sleeve gastrectomy instead of distal hemigastrectomy

bull Most women regained normal menstrual function and most had documented

spontaneous ovulation

bull Significant improvement in hirsutism androgen profiles and about a 50 reduction in

HOMA-IR

bull Follow up for more than 2 years showed that all women resumed normal menstrual

cycles HbA1C decreased from 82 to 51 in lt 3 months

bull 78 saw improvement in metabolic syndrome amp 48 showed improvement in PCOS

2 ROLE OF BARIATRIC SURGERY IN PCOS PATIENTS

bull Decrease menstrual irregularities bull PCOS women have less hyper androgenism

bull Sex hormone binding globulin increases bull LH and FSH levels have been reported to increase

bull Ovulatory function measured by luteal LH and Progesterone secretion improved bull Leptin levels decrease reflecting improved reproductive metabolic status

bull Subclinical hypothyroidism significantly reduced

THE SAFE TIMING OF PREGNANCYoptimal or minimal time gt12 months after bariatric surgery before becoming pregnant in order to allow the rapid weight loss and metabolic changes to subside

4 BARIATRIC SURGERY IN REPRODUCTIVE WOMEN

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)

The foregut hypothesis theory ndash 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

Effect of Bariatric Surgery on Diabetes Mellitus

Combined Gastric Restriction amp Malabsorption

Operative Risks (vs cholecystectomy)

Perioperative Mortality 1-2 vs 02-08 Early Complications 10 vs 29Late Complications 20 vs 1-2

LimitationsWidening of (unbanded) gastrojejunostomyExpansion of gastric pouch 25 with nearly 100 weight regainAdaptation of limb that receives the food

SUMMARY OF ALL TYPES OF SURGERY

bull LRYGBP ndash worlds best procedure 60-70 WL dumping syndrome malnutrition

bull LAGB- low complications varying range of wt loss frequent post-op visits ( 10)

bull DSBPD- more wt loss high complications good for high BMI gt 50 malabsorption +

bull VBG(vertical band gastroplasty) ndash longest available results good wt loss improved co-morbidities right for some ptsrisks too high to justify rewards

bull SG- needs long term research 1st step procedure low risks higher wt loss lesser complications pouch could Stretch over time long staple line could cause problems in future frequency is accelerating because of technical ease 1st stage procedure before bypass

Post-surgical Complications

Anastomosis leaks or staple line leaks Pulmonary Embolism or DVT Cholelithiasis Stomal ulceration Dumping syndrome Constipation

Anastamosis Leaks

Up to 7-10 days after surgery Most common at gastrojejunostomy enteroenterostomy Roux

limb stump staple line Can lead to peritonitis sepsis possible death Presentation

Tachycardia tachypnea Fever Ab painback pain Pelvic pressure or rebound tenderness

Anastamosis Leaks

Order Gastrograffin upper GI series Subclinical cases

Bowel rest Parenteral nutrition IV antibiotic if H pylori

Clinically suspect leak Laparoscopic evaluation and leak repair

Failure to evaluate is the most common cause of preventable major long-term disability or death in bariatric surgical patients

Pulmonary Embolism

Sudden cause of death up to one month after surgery 20-30 mortality rate High risk may have vena cava filter placement prior to surgery Prophylaxis with compression stockings and LMWH Early ambulation imperitive

Pulmonary Embolism

Presentation Profound hypoxia Hypotension Signs of sepsis

Immediate spiral chest CT Abdominal exploration if too large for machine No pathology start anticoagulation Too largehelliphellipNO SURGERY

Cholelithiasis

Up to 36 of patients within 6 months post-op Bile stasis leads to increased sludge and gallstones Prophylactic cholecystectomy prior to surgery if

evidence of existing sludge or stones Prevent post-operative disease with concurrent bariatric

surgery and cholecystectomy Prophylactic use of urosidol

Expensive and unpalatable

Stomal Ulceration

12-15 within 2-4 mos Post-surgery Etiology

Overabundant acid in pouch leads to excessive acid passing through stoma

Pouch tension and staple line breakdown NSAID use

Presentation Dyspepsia vomiting Epigastric or retrosternal pain

Stomal Ulceration

Treatment PPI carafate Antibiotics if H Pylori Avoid NSAIDS alcohol smoking

If no response to treatment Endoscopy Back to surgery for pouch revision or staple line repair

Dumping Syndrome

More than 15 patients Hypotention Tachycardia Lightheadedness syncope Flushing Abdominal cramping and diarrhea Nausea and vomiting

Dumping Syndrome

Occurs with high dose simple sugar ingestion Sugar in small intestine causes osmotic overload and fluid

shift from blood to intestine Increased intestinal volume leads to watery diarrhea Decreased blood volume leads to systemic changes Patient education

Eat slowly Avoid drinking before during and not until 30 minutes after meals

Constipation

Most common complaint Causes

Dehydration and decreased fluid intake post-operatively Increased metabolic water needs Calcium and iron supplement use following surgery

Treat with increased fluids and stool softeners

Nutritional Consequences

Iron deficiency anemia B12 deficiency Folate deficiency Calcium and Vitamin D deficiency

Not seen with purely restrictive surgeries

Iron deficiency and anemia

Common following RYGB As high as 49 of patients Multifactorial cause

Low gastric acid levels prohibit iron cleavage from food Absorption inhibited because no nutrient exposure to duodenum or

proximal jejunum Decrease in iron-rich food consumption due to intolerance

Treat with oral supplementation of ferrous sulfate or ferrous gluconate

Vitamin B12 deficiency

Up to 70 of patients Lack of hydrochloric acid and pepsin in stomach

Prevents B12 cleavage from food Affects secretion of intrinsic factor thus B12 absorption

Intolerance to meat and milk Oral supplementation usually adequate otherwise IM injections used

Folate Deficiency

40 of gastric bypass patients Complete absorption requires B12 Absorption dependent on HCl and upper 13 stomach Deficiency generally caused by decreased consumption Oral supplementation

Vitamin D and Calcium Deficiency

Vitamin D deficiency is common among obese people Calcium absorption decreased because duodenum is

bypassed Intolerance to dairy foods high in calcium Vitamin D is required for Ca++ absorption Prolonged deficiencies lead to

Bone resorption osteomalacia osteoporosis Treat with calcium citrate supplementation and 2 weekly

doses of Vitamin D

Nutritional Implications of Various Bariatric Surgeries(34)

bull RYGB Malabsorption of Vit B12 Vit B1 (thiamin) Vit D Vit K Folate Iron Calcium

bull LAGB Folic Acid deficiency

bull BPD and BPDDS Vit A D E and K deficiency Protein-Calorie Malnutrition Malabsorption of

Calcium Zinc Selenium Sodium Potassium Chloride Phosphorus Magnesium

Recommended Daily Supplements(4)

Multivitamin with iron (prenatal vitamin will have adeq amount of folic acid)

Calcium (citrate) with vitamin D (1200-1500 mg calcium with 800-1000 IU vitamin D)

Oral vitamin B12 (500-1000 mcg) Iron (65 mgday in elemental form)

Vitamin C (to increase absorption of Iron) Thiamin (10 mgday)

Diet Recommendations(3)

Reduce food volume Chew food very well Slow pace of eating No liquids with meals Encourage fruits and vegetables as diet progresses Include high protein foods (at least 60gday) may need protein

supplements

Diet Progression Gastric Bypass

Stage 1 Clear liquids and protein supplement (1 week)

Stage 2No concentrated sweets low fat puree diet ( 3 weeks)

Stage 3 Regular texture weight reduction diet

Diet Progression Lap - Band

Stage 1 Clear liquids and protein supplement ( 2 weeks)

Stage 2 No concentrated sweets low fat puree diet (2weeks)

Stage 3 Regular texture weight reduction diet

Stage 1

Only clear liquids allowed Avoid sweetened beverages Sip very slowly No straws Avoid caffeinated carbonated and alcoholic beverages STOP drinking if you feel fullness pain or discomfort

Protein supplements

Begin the day after you go home from Hospital

Minimum protein target 70gmsday

May use powder or pre-mixed liquid forms (Whey protein is preferred)

Protein pills may not be used

Vitamin and Mineral Supplements

Gastric bypass patients In addition to eating much less food gastric bypass patients will also

absorb vitamins and minerals differently after surgery They will require daily multivitamin calcium and iron

supplementation for the rest of your life

Vitamin and Mineral Supplements

Lap-Bandreg patients

Require a multivitamin with minerals daily

It may be necessary to take additional vitamins and minerals eg calcium iron folateB1 B12These will be prescribed as needed

Stage 2 dietPUREE

Puree diet

Regular scheduled meals Avoid meal skipping Plan meals in advance Eat Slowly Eat protein foods first Moisten meats Use liquid protein as supplement not as meal replacement

Measure 2 oz portions at each meal eating when full Separate liquids and solids No bread rice or pasta Avoid added sugars and high fat

foods VARIETY

How does surgery work

RESTRICTIVE - RESTRICT AMOUNT OF FOOD INGESTED Decreases appetitehunger

Early satiety Behavior modification Gastric Banding (Lap Band)

Roux-en Y Gastric bypass (RYGB) Sleeve Gastrectomy

MALABSORPTIVE- LIMITS DIGESTION AND ABSORPTION Decreases length of intestine exposed to digested food

25 of fat is absorbed Behavior modification

Biliopancreatic Diversion Duodenal Switch (BPDDS)

ALL OPERATIONS CAN BE PERFORMED OPEN OR LAPAROSCOPICALLY

Laparoscopic vs Open

OPEN uarr post op pain Longer hospitalizations uarr wound complications

Infection Hernias Seromas

Return to work in 4-8 weeks

LAPAROSCOPIC darr post op pain Early mobility darr Wound complications 2-3 day hospital stay Return to work in 1-3 weeks

1 Nguyen NT et al Accelerated growth of bariatric surgery with the introduction of minimally invasive surgery Arch Surg 20051401198-202

Procedures that are solely restrictive by creating a small gastric pouch of volume 15 to 30 cc amp a degree of outlet obstruction leading to delayed gastric emptying The goal is to reduce oral intake by limiting gastric volume produce early satiety and leave the alimentary canal in continuity minimizing the risks of metabolic complications

1VERTICAL BANDED GASTROPLASTY

2ADJUSTABLE GASTRIC BANDING (LAGB )

3 SLEEVE GASTRECTOMY

4GASTRIC PLICATION

5 INTRA GASTRIC BALLOON (GASTRIC BALLOON)

RESTRICTIVE PROCEDURES

Malabsorption is achieved by creating a short gut syndrome andor by accomplishing distal mixing of bile and pancreatic juice with ingested nutrients thereby reducing absorption Some purely malabsorptive operations are no longer recommended due to their potential hazard to cause serious nutritional deficiencies

1 BILIOPANCREATIC DIVERSION2 THE JEJUNAL-ILEAL BYPASS3 ENDOLUMINAL SLEEVE

MALABSORPTIVE PROCEDURES

MIXED PROCEDURES

1GASTRIC BYPASS ROUX-EN-Y ( RYGBP)

2SLEEVE GASTRECTOMY WITH DUODENAL SWITCH

3IMPLANTABLE 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

The stomach is partitioned along its axis with a non-

adjustable poly-urethane band and with linear amp 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 was practiced in 1980

Vertical Banded Gastroplasty (VBG)

ADJUSTABLE GASTRIC BANDING (LAP BAND SURGERY LAGB)

Restrictive Procedure The procedure was first performed by Cadiere in 1992 but was made popular by Belachew and Legrand in 1993 An inflatable silicone BAND is placed around the top portion of the stomach to form a small stomach pouch amp sewed

This band is connected to a tube that leads to a port above the abdominal muscles placed below the skin (FILL ndash PORT)

During follow up visits we inject or remove saline solution to make the band tighter or looser

Adjustable Gastric Band

bull 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

How does the Band work

Surgery Factors Restriction of meal size Decreased appetite

Patient Factors Decreased calorie intake Increased calorie expenditure

LAP-BAND Adjustability

Unfilled Band Filled Band

Adjustments are made in the office

Complications of Gastric Lap-Band

bull Perforation of Stomachbull Slippagebull Gastric Erosion(much less after Pars flaccida technique) bull Dilated Esophagusbull Tubing access port problemsbull Mal positioningbull Abdominal Painbull Heartburnbull Vomitingbull Inability to Adjust the Bandbull Failure to Lose Weightbull Infection of Systembull Fatigue or malfunction

Advantages

No intestinal surgery No staplingcutting of stomach No nutritional risks Adjustable Reversible Safe

Foreign body Frequent follow-up visits Needs more commitment Easy to cheat

Disadvantages

Comparison of Adjustable Gastric Banding and Vertical Banded Gastroplasty

Laparoscopic adjustable gastric banding Reversible Adjustable Simpler to perform laparoscopically Sustained weight loss of gt50 EBW gt5

years following surgery Complications Gastric prolapse band

erosion rarely gastric perforation and access port complications

Vertical banded gastroplasty Irreversible Non adjustable Technically difficult by laparoscopy Weight loss of 25-50 EBW and weight gain

after 2-3 years Complications suture line disruption gastric

leak weight gain

>

>

Originally used as the first-stage operation for a proposed biliopancreatic diversion with duodenal switch in high-risk patients

The sleeve gastrectomy has caught on as a primary obesity treatment as surgeons are reporting weight loss of 55 of excess body weight past 5 years in some patients

The sleeve gastrectomy is also known as the greater curvature gastrectomy vertical or longitudinal gastrectomy or Pylorus preserving lsquogastric tube creationrsquo

Rapid and less traumatic operation Good resolution of co-morbidities and good weight loss

A further second surgical step is then easily feasible if necessary

SLEEVE GASTRECTOMY

SLEEVE GASTRECTOMY

A sleeve gastrectomy involves resection of

approximately 80 of the greater curvature

side of the stomach

Smaller tubular gastric ldquosleeverdquo created

along the lesser curve that is based on the

lesser curvature blood supply

Ideal approximate capacity of the stomach

after the procedure is about 30- 60 ml pouch

1MECHANICAL RESTRICTION by reducing the volume of the stomach and impairing stomach mobility Also called lsquoFood limitingrsquo operation

2HORMONAL MODIFICATION by removing a great part of the Ghrelin (Hunger Hormone) production tissue

(Ghrelin is a 28 amino-acid-peptide secreted by the oxyntic glands of the gastric fungus It is a potent orexigenic (appetite-stimulating) peptide mediated by the activation of its receptors in the hypothalamus or pituitary area)

The gastric fundus contains 10 to 20 times more ghrelin per one gram of tissue than the duodenum In the SG resection of the fundus removes the major portion of ghrelin release therefore appetite decreases

The sleeve gastrectomy (SG) induces weight loss by 2 mechanisms

>

Intragastric balloon involves placing a deflated balloon into the stomach and then filling it to decrease the amount of gastric space

The balloon can be left in the stomach for a maximum of 6 months and results in an average weight loss of 5ndash9 BMI over half a year

Done endoscopically

The intragastric balloon may be used prior to another bariatric surgery as a step-down procedure

INTRA GASTRIC BALLOON

>

>

The EndoBarrier gastrointestinal liner mimics the effects of gastric bypass surgery

Itrsquos designed to work by inserting a flexible

tube-like barrier into the duodenum amp 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

ENDO BARRIER LINER SYSTEM

B MAL- ABSORPTIVE PROCEDURES

Malabsorptive surgeries rearrange andor remove part of digestive system which then limits the amount of calories and nutrients that body can absorb Treatment with a large malabsorptive component results in the most weight loss but tend to have slightly higher complication rates

1JEJUNAL ILEAL BYPASS ndash no longer performed for high complication rates

2ILEAL TRANSPOSITION- New malabsoptive procedure on trial for treatment of DM type 2 and metabolic disorders

C COMBINATION PROCEDURES RESTRICTIVE + MALABSORBTIVE

1LAP GASTRIC BYPASS ndash ROUX-EN- Y ndash more malabsorption than the restrictive

2MINI- GASTRIC BYPASS- mainly restrictive

3DUODENAL SWITCH ndash the sleeve stomach is the restrictive portion ampthe intestinal bypass (duodenal switch) is the malabsorptive component

When surgery combines both restrictive and malabsorptive techniques it is know as a ldquocombinationrdquo procedure Most types of bariatric surgery carry at least a small element of both components but the following surgeries achieve a notable portion of weight loss from eachhellip

1 LAP GASTRIC BYPASS LGB

The Roux-en-Y gastric bypass(known simply as the LRYGBP) is the most commonly performed procedure

It primarily causesweight loss by restricting thefood intake however there ismore amount of mal absorption that occurs with this operation

GASTRIC BYPASS LRYGBP

bullThe stomach is stapled into2 pieces one small and one large The small piece becomes the ldquonewrdquo stomach pouch

bull The larger portion of the stomach stays in place however will lie dormant for the remainder of the patientrsquos life

GASTRIC BYPASS LGB

bull The small intestine (the jejunum) is divided using a surgical staplerApprox 50-70 cm from the DJ Junction

GASTRIC BYPASS LGB

Y- LIMB BP LIMB

bull The end of the Roux limb is then attached to the newly formed stomach pouch which carries food to the distal intestine

bull The Roux loop is completed by forming a jejunostomy

bull The Y limb or BPD limb carries digestive juices from the pancreas gall bladder liver and duodenum to the intestines

bull The food and the digestive juices mix where the Roux limb and Y limb meet much below say 100-150 cm from DJ

Roux limb or alimentary limb

100-150 cm

How Does the Roux-en-Y Work

Surgery factors restriction of meal size ldquodumping syndromerdquo some malabsorption decreased appetite

Patient factors calorie intake calorie expenditure

bull Most commonly performedbull Most reliable operation for long term weight lossbull Long term weight loss averages 60 to 75 percent of EBWbull Malnutrition is unusualbull Substantial improvement amp resolution in many co-morbid

obesity conditions

ADVANTAGES OF RYGBP

1 Not reversible

2 Mortality 05- 1

3 Perioperative complications 5-10

4 Stricture of gastrojejunostomy-10 (long term)

5 Long term risk of protein amp vitamin deficiency and marginal ulceration of GJA

6Long term risk of intestinal obstruction ndash 2

LAPAROSCOPIC GASTRIC BYPASSCOMPLICATIONS

Biliopancreatic Diversion (BPD)

Primarily malabsorptive but restrictive component also

First Terminal ileum is measured to a length of 50 cms marked with suture

The alimentary tract beyond the proximal part of stomach is rearranged to

include only distal 200 cm of ileum including common channel

Common channel-Distal 50 cm of terminal ileum for absorption of fat and

protein

The proximal end of ileum anastomosed to proximal end of stomach after

performing distal hemigastrectomy

Biliopancreatic Diversion with Duodenal Switch

Modification to lessen high incidence of vit b12 deficiency anastomotic stricture at gastrojejunal anastomosis

This procedure involves a sleeve gastrectomy that is then diverted at the duodenum into the ileum at a point measured proximally from the ileocecal valve (usually 250 cm)

The distal duodenum and jejunum the biliopancreatic limb are then anastomosed to the ileum at a point measured proximally from the ileocecal valve (usually 100 cm)

Common channel is 100cm Entire alimentary tract is 250 cm This is the most aggressive bypass procedure commonly offered today Major difference-Sleeve gastrectomy instead of distal hemigastrectomy

bull Most women regained normal menstrual function and most had documented

spontaneous ovulation

bull Significant improvement in hirsutism androgen profiles and about a 50 reduction in

HOMA-IR

bull Follow up for more than 2 years showed that all women resumed normal menstrual

cycles HbA1C decreased from 82 to 51 in lt 3 months

bull 78 saw improvement in metabolic syndrome amp 48 showed improvement in PCOS

2 ROLE OF BARIATRIC SURGERY IN PCOS PATIENTS

bull Decrease menstrual irregularities bull PCOS women have less hyper androgenism

bull Sex hormone binding globulin increases bull LH and FSH levels have been reported to increase

bull Ovulatory function measured by luteal LH and Progesterone secretion improved bull Leptin levels decrease reflecting improved reproductive metabolic status

bull Subclinical hypothyroidism significantly reduced

THE SAFE TIMING OF PREGNANCYoptimal or minimal time gt12 months after bariatric surgery before becoming pregnant in order to allow the rapid weight loss and metabolic changes to subside

4 BARIATRIC SURGERY IN REPRODUCTIVE WOMEN

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)

The foregut hypothesis theory ndash 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

Effect of Bariatric Surgery on Diabetes Mellitus

Combined Gastric Restriction amp Malabsorption

Operative Risks (vs cholecystectomy)

Perioperative Mortality 1-2 vs 02-08 Early Complications 10 vs 29Late Complications 20 vs 1-2

LimitationsWidening of (unbanded) gastrojejunostomyExpansion of gastric pouch 25 with nearly 100 weight regainAdaptation of limb that receives the food

SUMMARY OF ALL TYPES OF SURGERY

bull LRYGBP ndash worlds best procedure 60-70 WL dumping syndrome malnutrition

bull LAGB- low complications varying range of wt loss frequent post-op visits ( 10)

bull DSBPD- more wt loss high complications good for high BMI gt 50 malabsorption +

bull VBG(vertical band gastroplasty) ndash longest available results good wt loss improved co-morbidities right for some ptsrisks too high to justify rewards

bull SG- needs long term research 1st step procedure low risks higher wt loss lesser complications pouch could Stretch over time long staple line could cause problems in future frequency is accelerating because of technical ease 1st stage procedure before bypass

Post-surgical Complications

Anastomosis leaks or staple line leaks Pulmonary Embolism or DVT Cholelithiasis Stomal ulceration Dumping syndrome Constipation

Anastamosis Leaks

Up to 7-10 days after surgery Most common at gastrojejunostomy enteroenterostomy Roux

limb stump staple line Can lead to peritonitis sepsis possible death Presentation

Tachycardia tachypnea Fever Ab painback pain Pelvic pressure or rebound tenderness

Anastamosis Leaks

Order Gastrograffin upper GI series Subclinical cases

Bowel rest Parenteral nutrition IV antibiotic if H pylori

Clinically suspect leak Laparoscopic evaluation and leak repair

Failure to evaluate is the most common cause of preventable major long-term disability or death in bariatric surgical patients

Pulmonary Embolism

Sudden cause of death up to one month after surgery 20-30 mortality rate High risk may have vena cava filter placement prior to surgery Prophylaxis with compression stockings and LMWH Early ambulation imperitive

Pulmonary Embolism

Presentation Profound hypoxia Hypotension Signs of sepsis

Immediate spiral chest CT Abdominal exploration if too large for machine No pathology start anticoagulation Too largehelliphellipNO SURGERY

Cholelithiasis

Up to 36 of patients within 6 months post-op Bile stasis leads to increased sludge and gallstones Prophylactic cholecystectomy prior to surgery if

evidence of existing sludge or stones Prevent post-operative disease with concurrent bariatric

surgery and cholecystectomy Prophylactic use of urosidol

Expensive and unpalatable

Stomal Ulceration

12-15 within 2-4 mos Post-surgery Etiology

Overabundant acid in pouch leads to excessive acid passing through stoma

Pouch tension and staple line breakdown NSAID use

Presentation Dyspepsia vomiting Epigastric or retrosternal pain

Stomal Ulceration

Treatment PPI carafate Antibiotics if H Pylori Avoid NSAIDS alcohol smoking

If no response to treatment Endoscopy Back to surgery for pouch revision or staple line repair

Dumping Syndrome

More than 15 patients Hypotention Tachycardia Lightheadedness syncope Flushing Abdominal cramping and diarrhea Nausea and vomiting

Dumping Syndrome

Occurs with high dose simple sugar ingestion Sugar in small intestine causes osmotic overload and fluid

shift from blood to intestine Increased intestinal volume leads to watery diarrhea Decreased blood volume leads to systemic changes Patient education

Eat slowly Avoid drinking before during and not until 30 minutes after meals

Constipation

Most common complaint Causes

Dehydration and decreased fluid intake post-operatively Increased metabolic water needs Calcium and iron supplement use following surgery

Treat with increased fluids and stool softeners

Nutritional Consequences

Iron deficiency anemia B12 deficiency Folate deficiency Calcium and Vitamin D deficiency

Not seen with purely restrictive surgeries

Iron deficiency and anemia

Common following RYGB As high as 49 of patients Multifactorial cause

Low gastric acid levels prohibit iron cleavage from food Absorption inhibited because no nutrient exposure to duodenum or

proximal jejunum Decrease in iron-rich food consumption due to intolerance

Treat with oral supplementation of ferrous sulfate or ferrous gluconate

Vitamin B12 deficiency

Up to 70 of patients Lack of hydrochloric acid and pepsin in stomach

Prevents B12 cleavage from food Affects secretion of intrinsic factor thus B12 absorption

Intolerance to meat and milk Oral supplementation usually adequate otherwise IM injections used

Folate Deficiency

40 of gastric bypass patients Complete absorption requires B12 Absorption dependent on HCl and upper 13 stomach Deficiency generally caused by decreased consumption Oral supplementation

Vitamin D and Calcium Deficiency

Vitamin D deficiency is common among obese people Calcium absorption decreased because duodenum is

bypassed Intolerance to dairy foods high in calcium Vitamin D is required for Ca++ absorption Prolonged deficiencies lead to

Bone resorption osteomalacia osteoporosis Treat with calcium citrate supplementation and 2 weekly

doses of Vitamin D

Nutritional Implications of Various Bariatric Surgeries(34)

bull RYGB Malabsorption of Vit B12 Vit B1 (thiamin) Vit D Vit K Folate Iron Calcium

bull LAGB Folic Acid deficiency

bull BPD and BPDDS Vit A D E and K deficiency Protein-Calorie Malnutrition Malabsorption of

Calcium Zinc Selenium Sodium Potassium Chloride Phosphorus Magnesium

Recommended Daily Supplements(4)

Multivitamin with iron (prenatal vitamin will have adeq amount of folic acid)

Calcium (citrate) with vitamin D (1200-1500 mg calcium with 800-1000 IU vitamin D)

Oral vitamin B12 (500-1000 mcg) Iron (65 mgday in elemental form)

Vitamin C (to increase absorption of Iron) Thiamin (10 mgday)

Diet Recommendations(3)

Reduce food volume Chew food very well Slow pace of eating No liquids with meals Encourage fruits and vegetables as diet progresses Include high protein foods (at least 60gday) may need protein

supplements

Diet Progression Gastric Bypass

Stage 1 Clear liquids and protein supplement (1 week)

Stage 2No concentrated sweets low fat puree diet ( 3 weeks)

Stage 3 Regular texture weight reduction diet

Diet Progression Lap - Band

Stage 1 Clear liquids and protein supplement ( 2 weeks)

Stage 2 No concentrated sweets low fat puree diet (2weeks)

Stage 3 Regular texture weight reduction diet

Stage 1

Only clear liquids allowed Avoid sweetened beverages Sip very slowly No straws Avoid caffeinated carbonated and alcoholic beverages STOP drinking if you feel fullness pain or discomfort

Protein supplements

Begin the day after you go home from Hospital

Minimum protein target 70gmsday

May use powder or pre-mixed liquid forms (Whey protein is preferred)

Protein pills may not be used

Vitamin and Mineral Supplements

Gastric bypass patients In addition to eating much less food gastric bypass patients will also

absorb vitamins and minerals differently after surgery They will require daily multivitamin calcium and iron

supplementation for the rest of your life

Vitamin and Mineral Supplements

Lap-Bandreg patients

Require a multivitamin with minerals daily

It may be necessary to take additional vitamins and minerals eg calcium iron folateB1 B12These will be prescribed as needed

Stage 2 dietPUREE

Puree diet

Regular scheduled meals Avoid meal skipping Plan meals in advance Eat Slowly Eat protein foods first Moisten meats Use liquid protein as supplement not as meal replacement

Measure 2 oz portions at each meal eating when full Separate liquids and solids No bread rice or pasta Avoid added sugars and high fat

foods VARIETY

Laparoscopic vs Open

OPEN uarr post op pain Longer hospitalizations uarr wound complications

Infection Hernias Seromas

Return to work in 4-8 weeks

LAPAROSCOPIC darr post op pain Early mobility darr Wound complications 2-3 day hospital stay Return to work in 1-3 weeks

1 Nguyen NT et al Accelerated growth of bariatric surgery with the introduction of minimally invasive surgery Arch Surg 20051401198-202

Procedures that are solely restrictive by creating a small gastric pouch of volume 15 to 30 cc amp a degree of outlet obstruction leading to delayed gastric emptying The goal is to reduce oral intake by limiting gastric volume produce early satiety and leave the alimentary canal in continuity minimizing the risks of metabolic complications

1VERTICAL BANDED GASTROPLASTY

2ADJUSTABLE GASTRIC BANDING (LAGB )

3 SLEEVE GASTRECTOMY

4GASTRIC PLICATION

5 INTRA GASTRIC BALLOON (GASTRIC BALLOON)

RESTRICTIVE PROCEDURES

Malabsorption is achieved by creating a short gut syndrome andor by accomplishing distal mixing of bile and pancreatic juice with ingested nutrients thereby reducing absorption Some purely malabsorptive operations are no longer recommended due to their potential hazard to cause serious nutritional deficiencies

1 BILIOPANCREATIC DIVERSION2 THE JEJUNAL-ILEAL BYPASS3 ENDOLUMINAL SLEEVE

MALABSORPTIVE PROCEDURES

MIXED PROCEDURES

1GASTRIC BYPASS ROUX-EN-Y ( RYGBP)

2SLEEVE GASTRECTOMY WITH DUODENAL SWITCH

3IMPLANTABLE 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

The stomach is partitioned along its axis with a non-

adjustable poly-urethane band and with linear amp 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 was practiced in 1980

Vertical Banded Gastroplasty (VBG)

ADJUSTABLE GASTRIC BANDING (LAP BAND SURGERY LAGB)

Restrictive Procedure The procedure was first performed by Cadiere in 1992 but was made popular by Belachew and Legrand in 1993 An inflatable silicone BAND is placed around the top portion of the stomach to form a small stomach pouch amp sewed

This band is connected to a tube that leads to a port above the abdominal muscles placed below the skin (FILL ndash PORT)

During follow up visits we inject or remove saline solution to make the band tighter or looser

Adjustable Gastric Band

bull 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

How does the Band work

Surgery Factors Restriction of meal size Decreased appetite

Patient Factors Decreased calorie intake Increased calorie expenditure

LAP-BAND Adjustability

Unfilled Band Filled Band

Adjustments are made in the office

Complications of Gastric Lap-Band

bull Perforation of Stomachbull Slippagebull Gastric Erosion(much less after Pars flaccida technique) bull Dilated Esophagusbull Tubing access port problemsbull Mal positioningbull Abdominal Painbull Heartburnbull Vomitingbull Inability to Adjust the Bandbull Failure to Lose Weightbull Infection of Systembull Fatigue or malfunction

Advantages

No intestinal surgery No staplingcutting of stomach No nutritional risks Adjustable Reversible Safe

Foreign body Frequent follow-up visits Needs more commitment Easy to cheat

Disadvantages

Comparison of Adjustable Gastric Banding and Vertical Banded Gastroplasty

Laparoscopic adjustable gastric banding Reversible Adjustable Simpler to perform laparoscopically Sustained weight loss of gt50 EBW gt5

years following surgery Complications Gastric prolapse band

erosion rarely gastric perforation and access port complications

Vertical banded gastroplasty Irreversible Non adjustable Technically difficult by laparoscopy Weight loss of 25-50 EBW and weight gain

after 2-3 years Complications suture line disruption gastric

leak weight gain

>

>

Originally used as the first-stage operation for a proposed biliopancreatic diversion with duodenal switch in high-risk patients

The sleeve gastrectomy has caught on as a primary obesity treatment as surgeons are reporting weight loss of 55 of excess body weight past 5 years in some patients

The sleeve gastrectomy is also known as the greater curvature gastrectomy vertical or longitudinal gastrectomy or Pylorus preserving lsquogastric tube creationrsquo

Rapid and less traumatic operation Good resolution of co-morbidities and good weight loss

A further second surgical step is then easily feasible if necessary

SLEEVE GASTRECTOMY

SLEEVE GASTRECTOMY

A sleeve gastrectomy involves resection of

approximately 80 of the greater curvature

side of the stomach

Smaller tubular gastric ldquosleeverdquo created

along the lesser curve that is based on the

lesser curvature blood supply

Ideal approximate capacity of the stomach

after the procedure is about 30- 60 ml pouch

1MECHANICAL RESTRICTION by reducing the volume of the stomach and impairing stomach mobility Also called lsquoFood limitingrsquo operation

2HORMONAL MODIFICATION by removing a great part of the Ghrelin (Hunger Hormone) production tissue

(Ghrelin is a 28 amino-acid-peptide secreted by the oxyntic glands of the gastric fungus It is a potent orexigenic (appetite-stimulating) peptide mediated by the activation of its receptors in the hypothalamus or pituitary area)

The gastric fundus contains 10 to 20 times more ghrelin per one gram of tissue than the duodenum In the SG resection of the fundus removes the major portion of ghrelin release therefore appetite decreases

The sleeve gastrectomy (SG) induces weight loss by 2 mechanisms

>

Intragastric balloon involves placing a deflated balloon into the stomach and then filling it to decrease the amount of gastric space

The balloon can be left in the stomach for a maximum of 6 months and results in an average weight loss of 5ndash9 BMI over half a year

Done endoscopically

The intragastric balloon may be used prior to another bariatric surgery as a step-down procedure

INTRA GASTRIC BALLOON

>

>

The EndoBarrier gastrointestinal liner mimics the effects of gastric bypass surgery

Itrsquos designed to work by inserting a flexible

tube-like barrier into the duodenum amp 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

ENDO BARRIER LINER SYSTEM

B MAL- ABSORPTIVE PROCEDURES

Malabsorptive surgeries rearrange andor remove part of digestive system which then limits the amount of calories and nutrients that body can absorb Treatment with a large malabsorptive component results in the most weight loss but tend to have slightly higher complication rates

1JEJUNAL ILEAL BYPASS ndash no longer performed for high complication rates

2ILEAL TRANSPOSITION- New malabsoptive procedure on trial for treatment of DM type 2 and metabolic disorders

C COMBINATION PROCEDURES RESTRICTIVE + MALABSORBTIVE

1LAP GASTRIC BYPASS ndash ROUX-EN- Y ndash more malabsorption than the restrictive

2MINI- GASTRIC BYPASS- mainly restrictive

3DUODENAL SWITCH ndash the sleeve stomach is the restrictive portion ampthe intestinal bypass (duodenal switch) is the malabsorptive component

When surgery combines both restrictive and malabsorptive techniques it is know as a ldquocombinationrdquo procedure Most types of bariatric surgery carry at least a small element of both components but the following surgeries achieve a notable portion of weight loss from eachhellip

1 LAP GASTRIC BYPASS LGB

The Roux-en-Y gastric bypass(known simply as the LRYGBP) is the most commonly performed procedure

It primarily causesweight loss by restricting thefood intake however there ismore amount of mal absorption that occurs with this operation

GASTRIC BYPASS LRYGBP

bullThe stomach is stapled into2 pieces one small and one large The small piece becomes the ldquonewrdquo stomach pouch

bull The larger portion of the stomach stays in place however will lie dormant for the remainder of the patientrsquos life

GASTRIC BYPASS LGB

bull The small intestine (the jejunum) is divided using a surgical staplerApprox 50-70 cm from the DJ Junction

GASTRIC BYPASS LGB

Y- LIMB BP LIMB

bull The end of the Roux limb is then attached to the newly formed stomach pouch which carries food to the distal intestine

bull The Roux loop is completed by forming a jejunostomy

bull The Y limb or BPD limb carries digestive juices from the pancreas gall bladder liver and duodenum to the intestines

bull The food and the digestive juices mix where the Roux limb and Y limb meet much below say 100-150 cm from DJ

Roux limb or alimentary limb

100-150 cm

How Does the Roux-en-Y Work

Surgery factors restriction of meal size ldquodumping syndromerdquo some malabsorption decreased appetite

Patient factors calorie intake calorie expenditure

bull Most commonly performedbull Most reliable operation for long term weight lossbull Long term weight loss averages 60 to 75 percent of EBWbull Malnutrition is unusualbull Substantial improvement amp resolution in many co-morbid

obesity conditions

ADVANTAGES OF RYGBP

1 Not reversible

2 Mortality 05- 1

3 Perioperative complications 5-10

4 Stricture of gastrojejunostomy-10 (long term)

5 Long term risk of protein amp vitamin deficiency and marginal ulceration of GJA

6Long term risk of intestinal obstruction ndash 2

LAPAROSCOPIC GASTRIC BYPASSCOMPLICATIONS

Biliopancreatic Diversion (BPD)

Primarily malabsorptive but restrictive component also

First Terminal ileum is measured to a length of 50 cms marked with suture

The alimentary tract beyond the proximal part of stomach is rearranged to

include only distal 200 cm of ileum including common channel

Common channel-Distal 50 cm of terminal ileum for absorption of fat and

protein

The proximal end of ileum anastomosed to proximal end of stomach after

performing distal hemigastrectomy

Biliopancreatic Diversion with Duodenal Switch

Modification to lessen high incidence of vit b12 deficiency anastomotic stricture at gastrojejunal anastomosis

This procedure involves a sleeve gastrectomy that is then diverted at the duodenum into the ileum at a point measured proximally from the ileocecal valve (usually 250 cm)

The distal duodenum and jejunum the biliopancreatic limb are then anastomosed to the ileum at a point measured proximally from the ileocecal valve (usually 100 cm)

Common channel is 100cm Entire alimentary tract is 250 cm This is the most aggressive bypass procedure commonly offered today Major difference-Sleeve gastrectomy instead of distal hemigastrectomy

bull Most women regained normal menstrual function and most had documented

spontaneous ovulation

bull Significant improvement in hirsutism androgen profiles and about a 50 reduction in

HOMA-IR

bull Follow up for more than 2 years showed that all women resumed normal menstrual

cycles HbA1C decreased from 82 to 51 in lt 3 months

bull 78 saw improvement in metabolic syndrome amp 48 showed improvement in PCOS

2 ROLE OF BARIATRIC SURGERY IN PCOS PATIENTS

bull Decrease menstrual irregularities bull PCOS women have less hyper androgenism

bull Sex hormone binding globulin increases bull LH and FSH levels have been reported to increase

bull Ovulatory function measured by luteal LH and Progesterone secretion improved bull Leptin levels decrease reflecting improved reproductive metabolic status

bull Subclinical hypothyroidism significantly reduced

THE SAFE TIMING OF PREGNANCYoptimal or minimal time gt12 months after bariatric surgery before becoming pregnant in order to allow the rapid weight loss and metabolic changes to subside

4 BARIATRIC SURGERY IN REPRODUCTIVE WOMEN

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)

The foregut hypothesis theory ndash 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

Effect of Bariatric Surgery on Diabetes Mellitus

Combined Gastric Restriction amp Malabsorption

Operative Risks (vs cholecystectomy)

Perioperative Mortality 1-2 vs 02-08 Early Complications 10 vs 29Late Complications 20 vs 1-2

LimitationsWidening of (unbanded) gastrojejunostomyExpansion of gastric pouch 25 with nearly 100 weight regainAdaptation of limb that receives the food

SUMMARY OF ALL TYPES OF SURGERY

bull LRYGBP ndash worlds best procedure 60-70 WL dumping syndrome malnutrition

bull LAGB- low complications varying range of wt loss frequent post-op visits ( 10)

bull DSBPD- more wt loss high complications good for high BMI gt 50 malabsorption +

bull VBG(vertical band gastroplasty) ndash longest available results good wt loss improved co-morbidities right for some ptsrisks too high to justify rewards

bull SG- needs long term research 1st step procedure low risks higher wt loss lesser complications pouch could Stretch over time long staple line could cause problems in future frequency is accelerating because of technical ease 1st stage procedure before bypass

Post-surgical Complications

Anastomosis leaks or staple line leaks Pulmonary Embolism or DVT Cholelithiasis Stomal ulceration Dumping syndrome Constipation

Anastamosis Leaks

Up to 7-10 days after surgery Most common at gastrojejunostomy enteroenterostomy Roux

limb stump staple line Can lead to peritonitis sepsis possible death Presentation

Tachycardia tachypnea Fever Ab painback pain Pelvic pressure or rebound tenderness

Anastamosis Leaks

Order Gastrograffin upper GI series Subclinical cases

Bowel rest Parenteral nutrition IV antibiotic if H pylori

Clinically suspect leak Laparoscopic evaluation and leak repair

Failure to evaluate is the most common cause of preventable major long-term disability or death in bariatric surgical patients

Pulmonary Embolism

Sudden cause of death up to one month after surgery 20-30 mortality rate High risk may have vena cava filter placement prior to surgery Prophylaxis with compression stockings and LMWH Early ambulation imperitive

Pulmonary Embolism

Presentation Profound hypoxia Hypotension Signs of sepsis

Immediate spiral chest CT Abdominal exploration if too large for machine No pathology start anticoagulation Too largehelliphellipNO SURGERY

Cholelithiasis

Up to 36 of patients within 6 months post-op Bile stasis leads to increased sludge and gallstones Prophylactic cholecystectomy prior to surgery if

evidence of existing sludge or stones Prevent post-operative disease with concurrent bariatric

surgery and cholecystectomy Prophylactic use of urosidol

Expensive and unpalatable

Stomal Ulceration

12-15 within 2-4 mos Post-surgery Etiology

Overabundant acid in pouch leads to excessive acid passing through stoma

Pouch tension and staple line breakdown NSAID use

Presentation Dyspepsia vomiting Epigastric or retrosternal pain

Stomal Ulceration

Treatment PPI carafate Antibiotics if H Pylori Avoid NSAIDS alcohol smoking

If no response to treatment Endoscopy Back to surgery for pouch revision or staple line repair

Dumping Syndrome

More than 15 patients Hypotention Tachycardia Lightheadedness syncope Flushing Abdominal cramping and diarrhea Nausea and vomiting

Dumping Syndrome

Occurs with high dose simple sugar ingestion Sugar in small intestine causes osmotic overload and fluid

shift from blood to intestine Increased intestinal volume leads to watery diarrhea Decreased blood volume leads to systemic changes Patient education

Eat slowly Avoid drinking before during and not until 30 minutes after meals

Constipation

Most common complaint Causes

Dehydration and decreased fluid intake post-operatively Increased metabolic water needs Calcium and iron supplement use following surgery

Treat with increased fluids and stool softeners

Nutritional Consequences

Iron deficiency anemia B12 deficiency Folate deficiency Calcium and Vitamin D deficiency

Not seen with purely restrictive surgeries

Iron deficiency and anemia

Common following RYGB As high as 49 of patients Multifactorial cause

Low gastric acid levels prohibit iron cleavage from food Absorption inhibited because no nutrient exposure to duodenum or

proximal jejunum Decrease in iron-rich food consumption due to intolerance

Treat with oral supplementation of ferrous sulfate or ferrous gluconate

Vitamin B12 deficiency

Up to 70 of patients Lack of hydrochloric acid and pepsin in stomach

Prevents B12 cleavage from food Affects secretion of intrinsic factor thus B12 absorption

Intolerance to meat and milk Oral supplementation usually adequate otherwise IM injections used

Folate Deficiency

40 of gastric bypass patients Complete absorption requires B12 Absorption dependent on HCl and upper 13 stomach Deficiency generally caused by decreased consumption Oral supplementation

Vitamin D and Calcium Deficiency

Vitamin D deficiency is common among obese people Calcium absorption decreased because duodenum is

bypassed Intolerance to dairy foods high in calcium Vitamin D is required for Ca++ absorption Prolonged deficiencies lead to

Bone resorption osteomalacia osteoporosis Treat with calcium citrate supplementation and 2 weekly

doses of Vitamin D

Nutritional Implications of Various Bariatric Surgeries(34)

bull RYGB Malabsorption of Vit B12 Vit B1 (thiamin) Vit D Vit K Folate Iron Calcium

bull LAGB Folic Acid deficiency

bull BPD and BPDDS Vit A D E and K deficiency Protein-Calorie Malnutrition Malabsorption of

Calcium Zinc Selenium Sodium Potassium Chloride Phosphorus Magnesium

Recommended Daily Supplements(4)

Multivitamin with iron (prenatal vitamin will have adeq amount of folic acid)

Calcium (citrate) with vitamin D (1200-1500 mg calcium with 800-1000 IU vitamin D)

Oral vitamin B12 (500-1000 mcg) Iron (65 mgday in elemental form)

Vitamin C (to increase absorption of Iron) Thiamin (10 mgday)

Diet Recommendations(3)

Reduce food volume Chew food very well Slow pace of eating No liquids with meals Encourage fruits and vegetables as diet progresses Include high protein foods (at least 60gday) may need protein

supplements

Diet Progression Gastric Bypass

Stage 1 Clear liquids and protein supplement (1 week)

Stage 2No concentrated sweets low fat puree diet ( 3 weeks)

Stage 3 Regular texture weight reduction diet

Diet Progression Lap - Band

Stage 1 Clear liquids and protein supplement ( 2 weeks)

Stage 2 No concentrated sweets low fat puree diet (2weeks)

Stage 3 Regular texture weight reduction diet

Stage 1

Only clear liquids allowed Avoid sweetened beverages Sip very slowly No straws Avoid caffeinated carbonated and alcoholic beverages STOP drinking if you feel fullness pain or discomfort

Protein supplements

Begin the day after you go home from Hospital

Minimum protein target 70gmsday

May use powder or pre-mixed liquid forms (Whey protein is preferred)

Protein pills may not be used

Vitamin and Mineral Supplements

Gastric bypass patients In addition to eating much less food gastric bypass patients will also

absorb vitamins and minerals differently after surgery They will require daily multivitamin calcium and iron

supplementation for the rest of your life

Vitamin and Mineral Supplements

Lap-Bandreg patients

Require a multivitamin with minerals daily

It may be necessary to take additional vitamins and minerals eg calcium iron folateB1 B12These will be prescribed as needed

Stage 2 dietPUREE

Puree diet

Regular scheduled meals Avoid meal skipping Plan meals in advance Eat Slowly Eat protein foods first Moisten meats Use liquid protein as supplement not as meal replacement

Measure 2 oz portions at each meal eating when full Separate liquids and solids No bread rice or pasta Avoid added sugars and high fat

foods VARIETY

Procedures that are solely restrictive by creating a small gastric pouch of volume 15 to 30 cc amp a degree of outlet obstruction leading to delayed gastric emptying The goal is to reduce oral intake by limiting gastric volume produce early satiety and leave the alimentary canal in continuity minimizing the risks of metabolic complications

1VERTICAL BANDED GASTROPLASTY

2ADJUSTABLE GASTRIC BANDING (LAGB )

3 SLEEVE GASTRECTOMY

4GASTRIC PLICATION

5 INTRA GASTRIC BALLOON (GASTRIC BALLOON)

RESTRICTIVE PROCEDURES

Malabsorption is achieved by creating a short gut syndrome andor by accomplishing distal mixing of bile and pancreatic juice with ingested nutrients thereby reducing absorption Some purely malabsorptive operations are no longer recommended due to their potential hazard to cause serious nutritional deficiencies

1 BILIOPANCREATIC DIVERSION2 THE JEJUNAL-ILEAL BYPASS3 ENDOLUMINAL SLEEVE

MALABSORPTIVE PROCEDURES

MIXED PROCEDURES

1GASTRIC BYPASS ROUX-EN-Y ( RYGBP)

2SLEEVE GASTRECTOMY WITH DUODENAL SWITCH

3IMPLANTABLE 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

The stomach is partitioned along its axis with a non-

adjustable poly-urethane band and with linear amp 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 was practiced in 1980

Vertical Banded Gastroplasty (VBG)

ADJUSTABLE GASTRIC BANDING (LAP BAND SURGERY LAGB)

Restrictive Procedure The procedure was first performed by Cadiere in 1992 but was made popular by Belachew and Legrand in 1993 An inflatable silicone BAND is placed around the top portion of the stomach to form a small stomach pouch amp sewed

This band is connected to a tube that leads to a port above the abdominal muscles placed below the skin (FILL ndash PORT)

During follow up visits we inject or remove saline solution to make the band tighter or looser

Adjustable Gastric Band

bull 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

How does the Band work

Surgery Factors Restriction of meal size Decreased appetite

Patient Factors Decreased calorie intake Increased calorie expenditure

LAP-BAND Adjustability

Unfilled Band Filled Band

Adjustments are made in the office

Complications of Gastric Lap-Band

bull Perforation of Stomachbull Slippagebull Gastric Erosion(much less after Pars flaccida technique) bull Dilated Esophagusbull Tubing access port problemsbull Mal positioningbull Abdominal Painbull Heartburnbull Vomitingbull Inability to Adjust the Bandbull Failure to Lose Weightbull Infection of Systembull Fatigue or malfunction

Advantages

No intestinal surgery No staplingcutting of stomach No nutritional risks Adjustable Reversible Safe

Foreign body Frequent follow-up visits Needs more commitment Easy to cheat

Disadvantages

Comparison of Adjustable Gastric Banding and Vertical Banded Gastroplasty

Laparoscopic adjustable gastric banding Reversible Adjustable Simpler to perform laparoscopically Sustained weight loss of gt50 EBW gt5

years following surgery Complications Gastric prolapse band

erosion rarely gastric perforation and access port complications

Vertical banded gastroplasty Irreversible Non adjustable Technically difficult by laparoscopy Weight loss of 25-50 EBW and weight gain

after 2-3 years Complications suture line disruption gastric

leak weight gain

>

>

Originally used as the first-stage operation for a proposed biliopancreatic diversion with duodenal switch in high-risk patients

The sleeve gastrectomy has caught on as a primary obesity treatment as surgeons are reporting weight loss of 55 of excess body weight past 5 years in some patients

The sleeve gastrectomy is also known as the greater curvature gastrectomy vertical or longitudinal gastrectomy or Pylorus preserving lsquogastric tube creationrsquo

Rapid and less traumatic operation Good resolution of co-morbidities and good weight loss

A further second surgical step is then easily feasible if necessary

SLEEVE GASTRECTOMY

SLEEVE GASTRECTOMY

A sleeve gastrectomy involves resection of

approximately 80 of the greater curvature

side of the stomach

Smaller tubular gastric ldquosleeverdquo created

along the lesser curve that is based on the

lesser curvature blood supply

Ideal approximate capacity of the stomach

after the procedure is about 30- 60 ml pouch

1MECHANICAL RESTRICTION by reducing the volume of the stomach and impairing stomach mobility Also called lsquoFood limitingrsquo operation

2HORMONAL MODIFICATION by removing a great part of the Ghrelin (Hunger Hormone) production tissue

(Ghrelin is a 28 amino-acid-peptide secreted by the oxyntic glands of the gastric fungus It is a potent orexigenic (appetite-stimulating) peptide mediated by the activation of its receptors in the hypothalamus or pituitary area)

The gastric fundus contains 10 to 20 times more ghrelin per one gram of tissue than the duodenum In the SG resection of the fundus removes the major portion of ghrelin release therefore appetite decreases

The sleeve gastrectomy (SG) induces weight loss by 2 mechanisms

>

Intragastric balloon involves placing a deflated balloon into the stomach and then filling it to decrease the amount of gastric space

The balloon can be left in the stomach for a maximum of 6 months and results in an average weight loss of 5ndash9 BMI over half a year

Done endoscopically

The intragastric balloon may be used prior to another bariatric surgery as a step-down procedure

INTRA GASTRIC BALLOON

>

>

The EndoBarrier gastrointestinal liner mimics the effects of gastric bypass surgery

Itrsquos designed to work by inserting a flexible

tube-like barrier into the duodenum amp 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

ENDO BARRIER LINER SYSTEM

B MAL- ABSORPTIVE PROCEDURES

Malabsorptive surgeries rearrange andor remove part of digestive system which then limits the amount of calories and nutrients that body can absorb Treatment with a large malabsorptive component results in the most weight loss but tend to have slightly higher complication rates

1JEJUNAL ILEAL BYPASS ndash no longer performed for high complication rates

2ILEAL TRANSPOSITION- New malabsoptive procedure on trial for treatment of DM type 2 and metabolic disorders

C COMBINATION PROCEDURES RESTRICTIVE + MALABSORBTIVE

1LAP GASTRIC BYPASS ndash ROUX-EN- Y ndash more malabsorption than the restrictive

2MINI- GASTRIC BYPASS- mainly restrictive

3DUODENAL SWITCH ndash the sleeve stomach is the restrictive portion ampthe intestinal bypass (duodenal switch) is the malabsorptive component

When surgery combines both restrictive and malabsorptive techniques it is know as a ldquocombinationrdquo procedure Most types of bariatric surgery carry at least a small element of both components but the following surgeries achieve a notable portion of weight loss from eachhellip

1 LAP GASTRIC BYPASS LGB

The Roux-en-Y gastric bypass(known simply as the LRYGBP) is the most commonly performed procedure

It primarily causesweight loss by restricting thefood intake however there ismore amount of mal absorption that occurs with this operation

GASTRIC BYPASS LRYGBP

bullThe stomach is stapled into2 pieces one small and one large The small piece becomes the ldquonewrdquo stomach pouch

bull The larger portion of the stomach stays in place however will lie dormant for the remainder of the patientrsquos life

GASTRIC BYPASS LGB

bull The small intestine (the jejunum) is divided using a surgical staplerApprox 50-70 cm from the DJ Junction

GASTRIC BYPASS LGB

Y- LIMB BP LIMB

bull The end of the Roux limb is then attached to the newly formed stomach pouch which carries food to the distal intestine

bull The Roux loop is completed by forming a jejunostomy

bull The Y limb or BPD limb carries digestive juices from the pancreas gall bladder liver and duodenum to the intestines

bull The food and the digestive juices mix where the Roux limb and Y limb meet much below say 100-150 cm from DJ

Roux limb or alimentary limb

100-150 cm

How Does the Roux-en-Y Work

Surgery factors restriction of meal size ldquodumping syndromerdquo some malabsorption decreased appetite

Patient factors calorie intake calorie expenditure

bull Most commonly performedbull Most reliable operation for long term weight lossbull Long term weight loss averages 60 to 75 percent of EBWbull Malnutrition is unusualbull Substantial improvement amp resolution in many co-morbid

obesity conditions

ADVANTAGES OF RYGBP

1 Not reversible

2 Mortality 05- 1

3 Perioperative complications 5-10

4 Stricture of gastrojejunostomy-10 (long term)

5 Long term risk of protein amp vitamin deficiency and marginal ulceration of GJA

6Long term risk of intestinal obstruction ndash 2

LAPAROSCOPIC GASTRIC BYPASSCOMPLICATIONS

Biliopancreatic Diversion (BPD)

Primarily malabsorptive but restrictive component also

First Terminal ileum is measured to a length of 50 cms marked with suture

The alimentary tract beyond the proximal part of stomach is rearranged to

include only distal 200 cm of ileum including common channel

Common channel-Distal 50 cm of terminal ileum for absorption of fat and

protein

The proximal end of ileum anastomosed to proximal end of stomach after

performing distal hemigastrectomy

Biliopancreatic Diversion with Duodenal Switch

Modification to lessen high incidence of vit b12 deficiency anastomotic stricture at gastrojejunal anastomosis

This procedure involves a sleeve gastrectomy that is then diverted at the duodenum into the ileum at a point measured proximally from the ileocecal valve (usually 250 cm)

The distal duodenum and jejunum the biliopancreatic limb are then anastomosed to the ileum at a point measured proximally from the ileocecal valve (usually 100 cm)

Common channel is 100cm Entire alimentary tract is 250 cm This is the most aggressive bypass procedure commonly offered today Major difference-Sleeve gastrectomy instead of distal hemigastrectomy

bull Most women regained normal menstrual function and most had documented

spontaneous ovulation

bull Significant improvement in hirsutism androgen profiles and about a 50 reduction in

HOMA-IR

bull Follow up for more than 2 years showed that all women resumed normal menstrual

cycles HbA1C decreased from 82 to 51 in lt 3 months

bull 78 saw improvement in metabolic syndrome amp 48 showed improvement in PCOS

2 ROLE OF BARIATRIC SURGERY IN PCOS PATIENTS

bull Decrease menstrual irregularities bull PCOS women have less hyper androgenism

bull Sex hormone binding globulin increases bull LH and FSH levels have been reported to increase

bull Ovulatory function measured by luteal LH and Progesterone secretion improved bull Leptin levels decrease reflecting improved reproductive metabolic status

bull Subclinical hypothyroidism significantly reduced

THE SAFE TIMING OF PREGNANCYoptimal or minimal time gt12 months after bariatric surgery before becoming pregnant in order to allow the rapid weight loss and metabolic changes to subside

4 BARIATRIC SURGERY IN REPRODUCTIVE WOMEN

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)

The foregut hypothesis theory ndash 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

Effect of Bariatric Surgery on Diabetes Mellitus

Combined Gastric Restriction amp Malabsorption

Operative Risks (vs cholecystectomy)

Perioperative Mortality 1-2 vs 02-08 Early Complications 10 vs 29Late Complications 20 vs 1-2

LimitationsWidening of (unbanded) gastrojejunostomyExpansion of gastric pouch 25 with nearly 100 weight regainAdaptation of limb that receives the food

SUMMARY OF ALL TYPES OF SURGERY

bull LRYGBP ndash worlds best procedure 60-70 WL dumping syndrome malnutrition

bull LAGB- low complications varying range of wt loss frequent post-op visits ( 10)

bull DSBPD- more wt loss high complications good for high BMI gt 50 malabsorption +

bull VBG(vertical band gastroplasty) ndash longest available results good wt loss improved co-morbidities right for some ptsrisks too high to justify rewards

bull SG- needs long term research 1st step procedure low risks higher wt loss lesser complications pouch could Stretch over time long staple line could cause problems in future frequency is accelerating because of technical ease 1st stage procedure before bypass

Post-surgical Complications

Anastomosis leaks or staple line leaks Pulmonary Embolism or DVT Cholelithiasis Stomal ulceration Dumping syndrome Constipation

Anastamosis Leaks

Up to 7-10 days after surgery Most common at gastrojejunostomy enteroenterostomy Roux

limb stump staple line Can lead to peritonitis sepsis possible death Presentation

Tachycardia tachypnea Fever Ab painback pain Pelvic pressure or rebound tenderness

Anastamosis Leaks

Order Gastrograffin upper GI series Subclinical cases

Bowel rest Parenteral nutrition IV antibiotic if H pylori

Clinically suspect leak Laparoscopic evaluation and leak repair

Failure to evaluate is the most common cause of preventable major long-term disability or death in bariatric surgical patients

Pulmonary Embolism

Sudden cause of death up to one month after surgery 20-30 mortality rate High risk may have vena cava filter placement prior to surgery Prophylaxis with compression stockings and LMWH Early ambulation imperitive

Pulmonary Embolism

Presentation Profound hypoxia Hypotension Signs of sepsis

Immediate spiral chest CT Abdominal exploration if too large for machine No pathology start anticoagulation Too largehelliphellipNO SURGERY

Cholelithiasis

Up to 36 of patients within 6 months post-op Bile stasis leads to increased sludge and gallstones Prophylactic cholecystectomy prior to surgery if

evidence of existing sludge or stones Prevent post-operative disease with concurrent bariatric

surgery and cholecystectomy Prophylactic use of urosidol

Expensive and unpalatable

Stomal Ulceration

12-15 within 2-4 mos Post-surgery Etiology

Overabundant acid in pouch leads to excessive acid passing through stoma

Pouch tension and staple line breakdown NSAID use

Presentation Dyspepsia vomiting Epigastric or retrosternal pain

Stomal Ulceration

Treatment PPI carafate Antibiotics if H Pylori Avoid NSAIDS alcohol smoking

If no response to treatment Endoscopy Back to surgery for pouch revision or staple line repair

Dumping Syndrome

More than 15 patients Hypotention Tachycardia Lightheadedness syncope Flushing Abdominal cramping and diarrhea Nausea and vomiting

Dumping Syndrome

Occurs with high dose simple sugar ingestion Sugar in small intestine causes osmotic overload and fluid

shift from blood to intestine Increased intestinal volume leads to watery diarrhea Decreased blood volume leads to systemic changes Patient education

Eat slowly Avoid drinking before during and not until 30 minutes after meals

Constipation

Most common complaint Causes

Dehydration and decreased fluid intake post-operatively Increased metabolic water needs Calcium and iron supplement use following surgery

Treat with increased fluids and stool softeners

Nutritional Consequences

Iron deficiency anemia B12 deficiency Folate deficiency Calcium and Vitamin D deficiency

Not seen with purely restrictive surgeries

Iron deficiency and anemia

Common following RYGB As high as 49 of patients Multifactorial cause

Low gastric acid levels prohibit iron cleavage from food Absorption inhibited because no nutrient exposure to duodenum or

proximal jejunum Decrease in iron-rich food consumption due to intolerance

Treat with oral supplementation of ferrous sulfate or ferrous gluconate

Vitamin B12 deficiency

Up to 70 of patients Lack of hydrochloric acid and pepsin in stomach

Prevents B12 cleavage from food Affects secretion of intrinsic factor thus B12 absorption

Intolerance to meat and milk Oral supplementation usually adequate otherwise IM injections used

Folate Deficiency

40 of gastric bypass patients Complete absorption requires B12 Absorption dependent on HCl and upper 13 stomach Deficiency generally caused by decreased consumption Oral supplementation

Vitamin D and Calcium Deficiency

Vitamin D deficiency is common among obese people Calcium absorption decreased because duodenum is

bypassed Intolerance to dairy foods high in calcium Vitamin D is required for Ca++ absorption Prolonged deficiencies lead to

Bone resorption osteomalacia osteoporosis Treat with calcium citrate supplementation and 2 weekly

doses of Vitamin D

Nutritional Implications of Various Bariatric Surgeries(34)

bull RYGB Malabsorption of Vit B12 Vit B1 (thiamin) Vit D Vit K Folate Iron Calcium

bull LAGB Folic Acid deficiency

bull BPD and BPDDS Vit A D E and K deficiency Protein-Calorie Malnutrition Malabsorption of

Calcium Zinc Selenium Sodium Potassium Chloride Phosphorus Magnesium

Recommended Daily Supplements(4)

Multivitamin with iron (prenatal vitamin will have adeq amount of folic acid)

Calcium (citrate) with vitamin D (1200-1500 mg calcium with 800-1000 IU vitamin D)

Oral vitamin B12 (500-1000 mcg) Iron (65 mgday in elemental form)

Vitamin C (to increase absorption of Iron) Thiamin (10 mgday)

Diet Recommendations(3)

Reduce food volume Chew food very well Slow pace of eating No liquids with meals Encourage fruits and vegetables as diet progresses Include high protein foods (at least 60gday) may need protein

supplements

Diet Progression Gastric Bypass

Stage 1 Clear liquids and protein supplement (1 week)

Stage 2No concentrated sweets low fat puree diet ( 3 weeks)

Stage 3 Regular texture weight reduction diet

Diet Progression Lap - Band

Stage 1 Clear liquids and protein supplement ( 2 weeks)

Stage 2 No concentrated sweets low fat puree diet (2weeks)

Stage 3 Regular texture weight reduction diet

Stage 1

Only clear liquids allowed Avoid sweetened beverages Sip very slowly No straws Avoid caffeinated carbonated and alcoholic beverages STOP drinking if you feel fullness pain or discomfort

Protein supplements

Begin the day after you go home from Hospital

Minimum protein target 70gmsday

May use powder or pre-mixed liquid forms (Whey protein is preferred)

Protein pills may not be used

Vitamin and Mineral Supplements

Gastric bypass patients In addition to eating much less food gastric bypass patients will also

absorb vitamins and minerals differently after surgery They will require daily multivitamin calcium and iron

supplementation for the rest of your life

Vitamin and Mineral Supplements

Lap-Bandreg patients

Require a multivitamin with minerals daily

It may be necessary to take additional vitamins and minerals eg calcium iron folateB1 B12These will be prescribed as needed

Stage 2 dietPUREE

Puree diet

Regular scheduled meals Avoid meal skipping Plan meals in advance Eat Slowly Eat protein foods first Moisten meats Use liquid protein as supplement not as meal replacement

Measure 2 oz portions at each meal eating when full Separate liquids and solids No bread rice or pasta Avoid added sugars and high fat

foods VARIETY

Malabsorption is achieved by creating a short gut syndrome andor by accomplishing distal mixing of bile and pancreatic juice with ingested nutrients thereby reducing absorption Some purely malabsorptive operations are no longer recommended due to their potential hazard to cause serious nutritional deficiencies

1 BILIOPANCREATIC DIVERSION2 THE JEJUNAL-ILEAL BYPASS3 ENDOLUMINAL SLEEVE

MALABSORPTIVE PROCEDURES

MIXED PROCEDURES

1GASTRIC BYPASS ROUX-EN-Y ( RYGBP)

2SLEEVE GASTRECTOMY WITH DUODENAL SWITCH

3IMPLANTABLE 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

The stomach is partitioned along its axis with a non-

adjustable poly-urethane band and with linear amp 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 was practiced in 1980

Vertical Banded Gastroplasty (VBG)

ADJUSTABLE GASTRIC BANDING (LAP BAND SURGERY LAGB)

Restrictive Procedure The procedure was first performed by Cadiere in 1992 but was made popular by Belachew and Legrand in 1993 An inflatable silicone BAND is placed around the top portion of the stomach to form a small stomach pouch amp sewed

This band is connected to a tube that leads to a port above the abdominal muscles placed below the skin (FILL ndash PORT)

During follow up visits we inject or remove saline solution to make the band tighter or looser

Adjustable Gastric Band

bull 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

How does the Band work

Surgery Factors Restriction of meal size Decreased appetite

Patient Factors Decreased calorie intake Increased calorie expenditure

LAP-BAND Adjustability

Unfilled Band Filled Band

Adjustments are made in the office

Complications of Gastric Lap-Band

bull Perforation of Stomachbull Slippagebull Gastric Erosion(much less after Pars flaccida technique) bull Dilated Esophagusbull Tubing access port problemsbull Mal positioningbull Abdominal Painbull Heartburnbull Vomitingbull Inability to Adjust the Bandbull Failure to Lose Weightbull Infection of Systembull Fatigue or malfunction

Advantages

No intestinal surgery No staplingcutting of stomach No nutritional risks Adjustable Reversible Safe

Foreign body Frequent follow-up visits Needs more commitment Easy to cheat

Disadvantages

Comparison of Adjustable Gastric Banding and Vertical Banded Gastroplasty

Laparoscopic adjustable gastric banding Reversible Adjustable Simpler to perform laparoscopically Sustained weight loss of gt50 EBW gt5

years following surgery Complications Gastric prolapse band

erosion rarely gastric perforation and access port complications

Vertical banded gastroplasty Irreversible Non adjustable Technically difficult by laparoscopy Weight loss of 25-50 EBW and weight gain

after 2-3 years Complications suture line disruption gastric

leak weight gain

>

>

Originally used as the first-stage operation for a proposed biliopancreatic diversion with duodenal switch in high-risk patients

The sleeve gastrectomy has caught on as a primary obesity treatment as surgeons are reporting weight loss of 55 of excess body weight past 5 years in some patients

The sleeve gastrectomy is also known as the greater curvature gastrectomy vertical or longitudinal gastrectomy or Pylorus preserving lsquogastric tube creationrsquo

Rapid and less traumatic operation Good resolution of co-morbidities and good weight loss

A further second surgical step is then easily feasible if necessary

SLEEVE GASTRECTOMY

SLEEVE GASTRECTOMY

A sleeve gastrectomy involves resection of

approximately 80 of the greater curvature

side of the stomach

Smaller tubular gastric ldquosleeverdquo created

along the lesser curve that is based on the

lesser curvature blood supply

Ideal approximate capacity of the stomach

after the procedure is about 30- 60 ml pouch

1MECHANICAL RESTRICTION by reducing the volume of the stomach and impairing stomach mobility Also called lsquoFood limitingrsquo operation

2HORMONAL MODIFICATION by removing a great part of the Ghrelin (Hunger Hormone) production tissue

(Ghrelin is a 28 amino-acid-peptide secreted by the oxyntic glands of the gastric fungus It is a potent orexigenic (appetite-stimulating) peptide mediated by the activation of its receptors in the hypothalamus or pituitary area)

The gastric fundus contains 10 to 20 times more ghrelin per one gram of tissue than the duodenum In the SG resection of the fundus removes the major portion of ghrelin release therefore appetite decreases

The sleeve gastrectomy (SG) induces weight loss by 2 mechanisms

>

Intragastric balloon involves placing a deflated balloon into the stomach and then filling it to decrease the amount of gastric space

The balloon can be left in the stomach for a maximum of 6 months and results in an average weight loss of 5ndash9 BMI over half a year

Done endoscopically

The intragastric balloon may be used prior to another bariatric surgery as a step-down procedure

INTRA GASTRIC BALLOON

>

>

The EndoBarrier gastrointestinal liner mimics the effects of gastric bypass surgery

Itrsquos designed to work by inserting a flexible

tube-like barrier into the duodenum amp 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

ENDO BARRIER LINER SYSTEM

B MAL- ABSORPTIVE PROCEDURES

Malabsorptive surgeries rearrange andor remove part of digestive system which then limits the amount of calories and nutrients that body can absorb Treatment with a large malabsorptive component results in the most weight loss but tend to have slightly higher complication rates

1JEJUNAL ILEAL BYPASS ndash no longer performed for high complication rates

2ILEAL TRANSPOSITION- New malabsoptive procedure on trial for treatment of DM type 2 and metabolic disorders

C COMBINATION PROCEDURES RESTRICTIVE + MALABSORBTIVE

1LAP GASTRIC BYPASS ndash ROUX-EN- Y ndash more malabsorption than the restrictive

2MINI- GASTRIC BYPASS- mainly restrictive

3DUODENAL SWITCH ndash the sleeve stomach is the restrictive portion ampthe intestinal bypass (duodenal switch) is the malabsorptive component

When surgery combines both restrictive and malabsorptive techniques it is know as a ldquocombinationrdquo procedure Most types of bariatric surgery carry at least a small element of both components but the following surgeries achieve a notable portion of weight loss from eachhellip

1 LAP GASTRIC BYPASS LGB

The Roux-en-Y gastric bypass(known simply as the LRYGBP) is the most commonly performed procedure

It primarily causesweight loss by restricting thefood intake however there ismore amount of mal absorption that occurs with this operation

GASTRIC BYPASS LRYGBP

bullThe stomach is stapled into2 pieces one small and one large The small piece becomes the ldquonewrdquo stomach pouch

bull The larger portion of the stomach stays in place however will lie dormant for the remainder of the patientrsquos life

GASTRIC BYPASS LGB

bull The small intestine (the jejunum) is divided using a surgical staplerApprox 50-70 cm from the DJ Junction

GASTRIC BYPASS LGB

Y- LIMB BP LIMB

bull The end of the Roux limb is then attached to the newly formed stomach pouch which carries food to the distal intestine

bull The Roux loop is completed by forming a jejunostomy

bull The Y limb or BPD limb carries digestive juices from the pancreas gall bladder liver and duodenum to the intestines

bull The food and the digestive juices mix where the Roux limb and Y limb meet much below say 100-150 cm from DJ

Roux limb or alimentary limb

100-150 cm

How Does the Roux-en-Y Work

Surgery factors restriction of meal size ldquodumping syndromerdquo some malabsorption decreased appetite

Patient factors calorie intake calorie expenditure

bull Most commonly performedbull Most reliable operation for long term weight lossbull Long term weight loss averages 60 to 75 percent of EBWbull Malnutrition is unusualbull Substantial improvement amp resolution in many co-morbid

obesity conditions

ADVANTAGES OF RYGBP

1 Not reversible

2 Mortality 05- 1

3 Perioperative complications 5-10

4 Stricture of gastrojejunostomy-10 (long term)

5 Long term risk of protein amp vitamin deficiency and marginal ulceration of GJA

6Long term risk of intestinal obstruction ndash 2

LAPAROSCOPIC GASTRIC BYPASSCOMPLICATIONS

Biliopancreatic Diversion (BPD)

Primarily malabsorptive but restrictive component also

First Terminal ileum is measured to a length of 50 cms marked with suture

The alimentary tract beyond the proximal part of stomach is rearranged to

include only distal 200 cm of ileum including common channel

Common channel-Distal 50 cm of terminal ileum for absorption of fat and

protein

The proximal end of ileum anastomosed to proximal end of stomach after

performing distal hemigastrectomy

Biliopancreatic Diversion with Duodenal Switch

Modification to lessen high incidence of vit b12 deficiency anastomotic stricture at gastrojejunal anastomosis

This procedure involves a sleeve gastrectomy that is then diverted at the duodenum into the ileum at a point measured proximally from the ileocecal valve (usually 250 cm)

The distal duodenum and jejunum the biliopancreatic limb are then anastomosed to the ileum at a point measured proximally from the ileocecal valve (usually 100 cm)

Common channel is 100cm Entire alimentary tract is 250 cm This is the most aggressive bypass procedure commonly offered today Major difference-Sleeve gastrectomy instead of distal hemigastrectomy

bull Most women regained normal menstrual function and most had documented

spontaneous ovulation

bull Significant improvement in hirsutism androgen profiles and about a 50 reduction in

HOMA-IR

bull Follow up for more than 2 years showed that all women resumed normal menstrual

cycles HbA1C decreased from 82 to 51 in lt 3 months

bull 78 saw improvement in metabolic syndrome amp 48 showed improvement in PCOS

2 ROLE OF BARIATRIC SURGERY IN PCOS PATIENTS

bull Decrease menstrual irregularities bull PCOS women have less hyper androgenism

bull Sex hormone binding globulin increases bull LH and FSH levels have been reported to increase

bull Ovulatory function measured by luteal LH and Progesterone secretion improved bull Leptin levels decrease reflecting improved reproductive metabolic status

bull Subclinical hypothyroidism significantly reduced

THE SAFE TIMING OF PREGNANCYoptimal or minimal time gt12 months after bariatric surgery before becoming pregnant in order to allow the rapid weight loss and metabolic changes to subside

4 BARIATRIC SURGERY IN REPRODUCTIVE WOMEN

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)

The foregut hypothesis theory ndash 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

Effect of Bariatric Surgery on Diabetes Mellitus

Combined Gastric Restriction amp Malabsorption

Operative Risks (vs cholecystectomy)

Perioperative Mortality 1-2 vs 02-08 Early Complications 10 vs 29Late Complications 20 vs 1-2

LimitationsWidening of (unbanded) gastrojejunostomyExpansion of gastric pouch 25 with nearly 100 weight regainAdaptation of limb that receives the food

SUMMARY OF ALL TYPES OF SURGERY

bull LRYGBP ndash worlds best procedure 60-70 WL dumping syndrome malnutrition

bull LAGB- low complications varying range of wt loss frequent post-op visits ( 10)

bull DSBPD- more wt loss high complications good for high BMI gt 50 malabsorption +

bull VBG(vertical band gastroplasty) ndash longest available results good wt loss improved co-morbidities right for some ptsrisks too high to justify rewards

bull SG- needs long term research 1st step procedure low risks higher wt loss lesser complications pouch could Stretch over time long staple line could cause problems in future frequency is accelerating because of technical ease 1st stage procedure before bypass

Post-surgical Complications

Anastomosis leaks or staple line leaks Pulmonary Embolism or DVT Cholelithiasis Stomal ulceration Dumping syndrome Constipation

Anastamosis Leaks

Up to 7-10 days after surgery Most common at gastrojejunostomy enteroenterostomy Roux

limb stump staple line Can lead to peritonitis sepsis possible death Presentation

Tachycardia tachypnea Fever Ab painback pain Pelvic pressure or rebound tenderness

Anastamosis Leaks

Order Gastrograffin upper GI series Subclinical cases

Bowel rest Parenteral nutrition IV antibiotic if H pylori

Clinically suspect leak Laparoscopic evaluation and leak repair

Failure to evaluate is the most common cause of preventable major long-term disability or death in bariatric surgical patients

Pulmonary Embolism

Sudden cause of death up to one month after surgery 20-30 mortality rate High risk may have vena cava filter placement prior to surgery Prophylaxis with compression stockings and LMWH Early ambulation imperitive

Pulmonary Embolism

Presentation Profound hypoxia Hypotension Signs of sepsis

Immediate spiral chest CT Abdominal exploration if too large for machine No pathology start anticoagulation Too largehelliphellipNO SURGERY

Cholelithiasis

Up to 36 of patients within 6 months post-op Bile stasis leads to increased sludge and gallstones Prophylactic cholecystectomy prior to surgery if

evidence of existing sludge or stones Prevent post-operative disease with concurrent bariatric

surgery and cholecystectomy Prophylactic use of urosidol

Expensive and unpalatable

Stomal Ulceration

12-15 within 2-4 mos Post-surgery Etiology

Overabundant acid in pouch leads to excessive acid passing through stoma

Pouch tension and staple line breakdown NSAID use

Presentation Dyspepsia vomiting Epigastric or retrosternal pain

Stomal Ulceration

Treatment PPI carafate Antibiotics if H Pylori Avoid NSAIDS alcohol smoking

If no response to treatment Endoscopy Back to surgery for pouch revision or staple line repair

Dumping Syndrome

More than 15 patients Hypotention Tachycardia Lightheadedness syncope Flushing Abdominal cramping and diarrhea Nausea and vomiting

Dumping Syndrome

Occurs with high dose simple sugar ingestion Sugar in small intestine causes osmotic overload and fluid

shift from blood to intestine Increased intestinal volume leads to watery diarrhea Decreased blood volume leads to systemic changes Patient education

Eat slowly Avoid drinking before during and not until 30 minutes after meals

Constipation

Most common complaint Causes

Dehydration and decreased fluid intake post-operatively Increased metabolic water needs Calcium and iron supplement use following surgery

Treat with increased fluids and stool softeners

Nutritional Consequences

Iron deficiency anemia B12 deficiency Folate deficiency Calcium and Vitamin D deficiency

Not seen with purely restrictive surgeries

Iron deficiency and anemia

Common following RYGB As high as 49 of patients Multifactorial cause

Low gastric acid levels prohibit iron cleavage from food Absorption inhibited because no nutrient exposure to duodenum or

proximal jejunum Decrease in iron-rich food consumption due to intolerance

Treat with oral supplementation of ferrous sulfate or ferrous gluconate

Vitamin B12 deficiency

Up to 70 of patients Lack of hydrochloric acid and pepsin in stomach

Prevents B12 cleavage from food Affects secretion of intrinsic factor thus B12 absorption

Intolerance to meat and milk Oral supplementation usually adequate otherwise IM injections used

Folate Deficiency

40 of gastric bypass patients Complete absorption requires B12 Absorption dependent on HCl and upper 13 stomach Deficiency generally caused by decreased consumption Oral supplementation

Vitamin D and Calcium Deficiency

Vitamin D deficiency is common among obese people Calcium absorption decreased because duodenum is

bypassed Intolerance to dairy foods high in calcium Vitamin D is required for Ca++ absorption Prolonged deficiencies lead to

Bone resorption osteomalacia osteoporosis Treat with calcium citrate supplementation and 2 weekly

doses of Vitamin D

Nutritional Implications of Various Bariatric Surgeries(34)

bull RYGB Malabsorption of Vit B12 Vit B1 (thiamin) Vit D Vit K Folate Iron Calcium

bull LAGB Folic Acid deficiency

bull BPD and BPDDS Vit A D E and K deficiency Protein-Calorie Malnutrition Malabsorption of

Calcium Zinc Selenium Sodium Potassium Chloride Phosphorus Magnesium

Recommended Daily Supplements(4)

Multivitamin with iron (prenatal vitamin will have adeq amount of folic acid)

Calcium (citrate) with vitamin D (1200-1500 mg calcium with 800-1000 IU vitamin D)

Oral vitamin B12 (500-1000 mcg) Iron (65 mgday in elemental form)

Vitamin C (to increase absorption of Iron) Thiamin (10 mgday)

Diet Recommendations(3)

Reduce food volume Chew food very well Slow pace of eating No liquids with meals Encourage fruits and vegetables as diet progresses Include high protein foods (at least 60gday) may need protein

supplements

Diet Progression Gastric Bypass

Stage 1 Clear liquids and protein supplement (1 week)

Stage 2No concentrated sweets low fat puree diet ( 3 weeks)

Stage 3 Regular texture weight reduction diet

Diet Progression Lap - Band

Stage 1 Clear liquids and protein supplement ( 2 weeks)

Stage 2 No concentrated sweets low fat puree diet (2weeks)

Stage 3 Regular texture weight reduction diet

Stage 1

Only clear liquids allowed Avoid sweetened beverages Sip very slowly No straws Avoid caffeinated carbonated and alcoholic beverages STOP drinking if you feel fullness pain or discomfort

Protein supplements

Begin the day after you go home from Hospital

Minimum protein target 70gmsday

May use powder or pre-mixed liquid forms (Whey protein is preferred)

Protein pills may not be used

Vitamin and Mineral Supplements

Gastric bypass patients In addition to eating much less food gastric bypass patients will also

absorb vitamins and minerals differently after surgery They will require daily multivitamin calcium and iron

supplementation for the rest of your life

Vitamin and Mineral Supplements

Lap-Bandreg patients

Require a multivitamin with minerals daily

It may be necessary to take additional vitamins and minerals eg calcium iron folateB1 B12These will be prescribed as needed

Stage 2 dietPUREE

Puree diet

Regular scheduled meals Avoid meal skipping Plan meals in advance Eat Slowly Eat protein foods first Moisten meats Use liquid protein as supplement not as meal replacement

Measure 2 oz portions at each meal eating when full Separate liquids and solids No bread rice or pasta Avoid added sugars and high fat

foods VARIETY

MIXED PROCEDURES

1GASTRIC BYPASS ROUX-EN-Y ( RYGBP)

2SLEEVE GASTRECTOMY WITH DUODENAL SWITCH

3IMPLANTABLE 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

The stomach is partitioned along its axis with a non-

adjustable poly-urethane band and with linear amp 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 was practiced in 1980

Vertical Banded Gastroplasty (VBG)

ADJUSTABLE GASTRIC BANDING (LAP BAND SURGERY LAGB)

Restrictive Procedure The procedure was first performed by Cadiere in 1992 but was made popular by Belachew and Legrand in 1993 An inflatable silicone BAND is placed around the top portion of the stomach to form a small stomach pouch amp sewed

This band is connected to a tube that leads to a port above the abdominal muscles placed below the skin (FILL ndash PORT)

During follow up visits we inject or remove saline solution to make the band tighter or looser

Adjustable Gastric Band

bull 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

How does the Band work

Surgery Factors Restriction of meal size Decreased appetite

Patient Factors Decreased calorie intake Increased calorie expenditure

LAP-BAND Adjustability

Unfilled Band Filled Band

Adjustments are made in the office

Complications of Gastric Lap-Band

bull Perforation of Stomachbull Slippagebull Gastric Erosion(much less after Pars flaccida technique) bull Dilated Esophagusbull Tubing access port problemsbull Mal positioningbull Abdominal Painbull Heartburnbull Vomitingbull Inability to Adjust the Bandbull Failure to Lose Weightbull Infection of Systembull Fatigue or malfunction

Advantages

No intestinal surgery No staplingcutting of stomach No nutritional risks Adjustable Reversible Safe

Foreign body Frequent follow-up visits Needs more commitment Easy to cheat

Disadvantages

Comparison of Adjustable Gastric Banding and Vertical Banded Gastroplasty

Laparoscopic adjustable gastric banding Reversible Adjustable Simpler to perform laparoscopically Sustained weight loss of gt50 EBW gt5

years following surgery Complications Gastric prolapse band

erosion rarely gastric perforation and access port complications

Vertical banded gastroplasty Irreversible Non adjustable Technically difficult by laparoscopy Weight loss of 25-50 EBW and weight gain

after 2-3 years Complications suture line disruption gastric

leak weight gain

>

>

Originally used as the first-stage operation for a proposed biliopancreatic diversion with duodenal switch in high-risk patients

The sleeve gastrectomy has caught on as a primary obesity treatment as surgeons are reporting weight loss of 55 of excess body weight past 5 years in some patients

The sleeve gastrectomy is also known as the greater curvature gastrectomy vertical or longitudinal gastrectomy or Pylorus preserving lsquogastric tube creationrsquo

Rapid and less traumatic operation Good resolution of co-morbidities and good weight loss

A further second surgical step is then easily feasible if necessary

SLEEVE GASTRECTOMY

SLEEVE GASTRECTOMY

A sleeve gastrectomy involves resection of

approximately 80 of the greater curvature

side of the stomach

Smaller tubular gastric ldquosleeverdquo created

along the lesser curve that is based on the

lesser curvature blood supply

Ideal approximate capacity of the stomach

after the procedure is about 30- 60 ml pouch

1MECHANICAL RESTRICTION by reducing the volume of the stomach and impairing stomach mobility Also called lsquoFood limitingrsquo operation

2HORMONAL MODIFICATION by removing a great part of the Ghrelin (Hunger Hormone) production tissue

(Ghrelin is a 28 amino-acid-peptide secreted by the oxyntic glands of the gastric fungus It is a potent orexigenic (appetite-stimulating) peptide mediated by the activation of its receptors in the hypothalamus or pituitary area)

The gastric fundus contains 10 to 20 times more ghrelin per one gram of tissue than the duodenum In the SG resection of the fundus removes the major portion of ghrelin release therefore appetite decreases

The sleeve gastrectomy (SG) induces weight loss by 2 mechanisms

>

Intragastric balloon involves placing a deflated balloon into the stomach and then filling it to decrease the amount of gastric space

The balloon can be left in the stomach for a maximum of 6 months and results in an average weight loss of 5ndash9 BMI over half a year

Done endoscopically

The intragastric balloon may be used prior to another bariatric surgery as a step-down procedure

INTRA GASTRIC BALLOON

>

>

The EndoBarrier gastrointestinal liner mimics the effects of gastric bypass surgery

Itrsquos designed to work by inserting a flexible

tube-like barrier into the duodenum amp 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

ENDO BARRIER LINER SYSTEM

B MAL- ABSORPTIVE PROCEDURES

Malabsorptive surgeries rearrange andor remove part of digestive system which then limits the amount of calories and nutrients that body can absorb Treatment with a large malabsorptive component results in the most weight loss but tend to have slightly higher complication rates

1JEJUNAL ILEAL BYPASS ndash no longer performed for high complication rates

2ILEAL TRANSPOSITION- New malabsoptive procedure on trial for treatment of DM type 2 and metabolic disorders

C COMBINATION PROCEDURES RESTRICTIVE + MALABSORBTIVE

1LAP GASTRIC BYPASS ndash ROUX-EN- Y ndash more malabsorption than the restrictive

2MINI- GASTRIC BYPASS- mainly restrictive

3DUODENAL SWITCH ndash the sleeve stomach is the restrictive portion ampthe intestinal bypass (duodenal switch) is the malabsorptive component

When surgery combines both restrictive and malabsorptive techniques it is know as a ldquocombinationrdquo procedure Most types of bariatric surgery carry at least a small element of both components but the following surgeries achieve a notable portion of weight loss from eachhellip

1 LAP GASTRIC BYPASS LGB

The Roux-en-Y gastric bypass(known simply as the LRYGBP) is the most commonly performed procedure

It primarily causesweight loss by restricting thefood intake however there ismore amount of mal absorption that occurs with this operation

GASTRIC BYPASS LRYGBP

bullThe stomach is stapled into2 pieces one small and one large The small piece becomes the ldquonewrdquo stomach pouch

bull The larger portion of the stomach stays in place however will lie dormant for the remainder of the patientrsquos life

GASTRIC BYPASS LGB

bull The small intestine (the jejunum) is divided using a surgical staplerApprox 50-70 cm from the DJ Junction

GASTRIC BYPASS LGB

Y- LIMB BP LIMB

bull The end of the Roux limb is then attached to the newly formed stomach pouch which carries food to the distal intestine

bull The Roux loop is completed by forming a jejunostomy

bull The Y limb or BPD limb carries digestive juices from the pancreas gall bladder liver and duodenum to the intestines

bull The food and the digestive juices mix where the Roux limb and Y limb meet much below say 100-150 cm from DJ

Roux limb or alimentary limb

100-150 cm

How Does the Roux-en-Y Work

Surgery factors restriction of meal size ldquodumping syndromerdquo some malabsorption decreased appetite

Patient factors calorie intake calorie expenditure

bull Most commonly performedbull Most reliable operation for long term weight lossbull Long term weight loss averages 60 to 75 percent of EBWbull Malnutrition is unusualbull Substantial improvement amp resolution in many co-morbid

obesity conditions

ADVANTAGES OF RYGBP

1 Not reversible

2 Mortality 05- 1

3 Perioperative complications 5-10

4 Stricture of gastrojejunostomy-10 (long term)

5 Long term risk of protein amp vitamin deficiency and marginal ulceration of GJA

6Long term risk of intestinal obstruction ndash 2

LAPAROSCOPIC GASTRIC BYPASSCOMPLICATIONS

Biliopancreatic Diversion (BPD)

Primarily malabsorptive but restrictive component also

First Terminal ileum is measured to a length of 50 cms marked with suture

The alimentary tract beyond the proximal part of stomach is rearranged to

include only distal 200 cm of ileum including common channel

Common channel-Distal 50 cm of terminal ileum for absorption of fat and

protein

The proximal end of ileum anastomosed to proximal end of stomach after

performing distal hemigastrectomy

Biliopancreatic Diversion with Duodenal Switch

Modification to lessen high incidence of vit b12 deficiency anastomotic stricture at gastrojejunal anastomosis

This procedure involves a sleeve gastrectomy that is then diverted at the duodenum into the ileum at a point measured proximally from the ileocecal valve (usually 250 cm)

The distal duodenum and jejunum the biliopancreatic limb are then anastomosed to the ileum at a point measured proximally from the ileocecal valve (usually 100 cm)

Common channel is 100cm Entire alimentary tract is 250 cm This is the most aggressive bypass procedure commonly offered today Major difference-Sleeve gastrectomy instead of distal hemigastrectomy

bull Most women regained normal menstrual function and most had documented

spontaneous ovulation

bull Significant improvement in hirsutism androgen profiles and about a 50 reduction in

HOMA-IR

bull Follow up for more than 2 years showed that all women resumed normal menstrual

cycles HbA1C decreased from 82 to 51 in lt 3 months

bull 78 saw improvement in metabolic syndrome amp 48 showed improvement in PCOS

2 ROLE OF BARIATRIC SURGERY IN PCOS PATIENTS

bull Decrease menstrual irregularities bull PCOS women have less hyper androgenism

bull Sex hormone binding globulin increases bull LH and FSH levels have been reported to increase

bull Ovulatory function measured by luteal LH and Progesterone secretion improved bull Leptin levels decrease reflecting improved reproductive metabolic status

bull Subclinical hypothyroidism significantly reduced

THE SAFE TIMING OF PREGNANCYoptimal or minimal time gt12 months after bariatric surgery before becoming pregnant in order to allow the rapid weight loss and metabolic changes to subside

4 BARIATRIC SURGERY IN REPRODUCTIVE WOMEN

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)

The foregut hypothesis theory ndash 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

Effect of Bariatric Surgery on Diabetes Mellitus

Combined Gastric Restriction amp Malabsorption

Operative Risks (vs cholecystectomy)

Perioperative Mortality 1-2 vs 02-08 Early Complications 10 vs 29Late Complications 20 vs 1-2

LimitationsWidening of (unbanded) gastrojejunostomyExpansion of gastric pouch 25 with nearly 100 weight regainAdaptation of limb that receives the food

SUMMARY OF ALL TYPES OF SURGERY

bull LRYGBP ndash worlds best procedure 60-70 WL dumping syndrome malnutrition

bull LAGB- low complications varying range of wt loss frequent post-op visits ( 10)

bull DSBPD- more wt loss high complications good for high BMI gt 50 malabsorption +

bull VBG(vertical band gastroplasty) ndash longest available results good wt loss improved co-morbidities right for some ptsrisks too high to justify rewards

bull SG- needs long term research 1st step procedure low risks higher wt loss lesser complications pouch could Stretch over time long staple line could cause problems in future frequency is accelerating because of technical ease 1st stage procedure before bypass

Post-surgical Complications

Anastomosis leaks or staple line leaks Pulmonary Embolism or DVT Cholelithiasis Stomal ulceration Dumping syndrome Constipation

Anastamosis Leaks

Up to 7-10 days after surgery Most common at gastrojejunostomy enteroenterostomy Roux

limb stump staple line Can lead to peritonitis sepsis possible death Presentation

Tachycardia tachypnea Fever Ab painback pain Pelvic pressure or rebound tenderness

Anastamosis Leaks

Order Gastrograffin upper GI series Subclinical cases

Bowel rest Parenteral nutrition IV antibiotic if H pylori

Clinically suspect leak Laparoscopic evaluation and leak repair

Failure to evaluate is the most common cause of preventable major long-term disability or death in bariatric surgical patients

Pulmonary Embolism

Sudden cause of death up to one month after surgery 20-30 mortality rate High risk may have vena cava filter placement prior to surgery Prophylaxis with compression stockings and LMWH Early ambulation imperitive

Pulmonary Embolism

Presentation Profound hypoxia Hypotension Signs of sepsis

Immediate spiral chest CT Abdominal exploration if too large for machine No pathology start anticoagulation Too largehelliphellipNO SURGERY

Cholelithiasis

Up to 36 of patients within 6 months post-op Bile stasis leads to increased sludge and gallstones Prophylactic cholecystectomy prior to surgery if

evidence of existing sludge or stones Prevent post-operative disease with concurrent bariatric

surgery and cholecystectomy Prophylactic use of urosidol

Expensive and unpalatable

Stomal Ulceration

12-15 within 2-4 mos Post-surgery Etiology

Overabundant acid in pouch leads to excessive acid passing through stoma

Pouch tension and staple line breakdown NSAID use

Presentation Dyspepsia vomiting Epigastric or retrosternal pain

Stomal Ulceration

Treatment PPI carafate Antibiotics if H Pylori Avoid NSAIDS alcohol smoking

If no response to treatment Endoscopy Back to surgery for pouch revision or staple line repair

Dumping Syndrome

More than 15 patients Hypotention Tachycardia Lightheadedness syncope Flushing Abdominal cramping and diarrhea Nausea and vomiting

Dumping Syndrome

Occurs with high dose simple sugar ingestion Sugar in small intestine causes osmotic overload and fluid

shift from blood to intestine Increased intestinal volume leads to watery diarrhea Decreased blood volume leads to systemic changes Patient education

Eat slowly Avoid drinking before during and not until 30 minutes after meals

Constipation

Most common complaint Causes

Dehydration and decreased fluid intake post-operatively Increased metabolic water needs Calcium and iron supplement use following surgery

Treat with increased fluids and stool softeners

Nutritional Consequences

Iron deficiency anemia B12 deficiency Folate deficiency Calcium and Vitamin D deficiency

Not seen with purely restrictive surgeries

Iron deficiency and anemia

Common following RYGB As high as 49 of patients Multifactorial cause

Low gastric acid levels prohibit iron cleavage from food Absorption inhibited because no nutrient exposure to duodenum or

proximal jejunum Decrease in iron-rich food consumption due to intolerance

Treat with oral supplementation of ferrous sulfate or ferrous gluconate

Vitamin B12 deficiency

Up to 70 of patients Lack of hydrochloric acid and pepsin in stomach

Prevents B12 cleavage from food Affects secretion of intrinsic factor thus B12 absorption

Intolerance to meat and milk Oral supplementation usually adequate otherwise IM injections used

Folate Deficiency

40 of gastric bypass patients Complete absorption requires B12 Absorption dependent on HCl and upper 13 stomach Deficiency generally caused by decreased consumption Oral supplementation

Vitamin D and Calcium Deficiency

Vitamin D deficiency is common among obese people Calcium absorption decreased because duodenum is

bypassed Intolerance to dairy foods high in calcium Vitamin D is required for Ca++ absorption Prolonged deficiencies lead to

Bone resorption osteomalacia osteoporosis Treat with calcium citrate supplementation and 2 weekly

doses of Vitamin D

Nutritional Implications of Various Bariatric Surgeries(34)

bull RYGB Malabsorption of Vit B12 Vit B1 (thiamin) Vit D Vit K Folate Iron Calcium

bull LAGB Folic Acid deficiency

bull BPD and BPDDS Vit A D E and K deficiency Protein-Calorie Malnutrition Malabsorption of

Calcium Zinc Selenium Sodium Potassium Chloride Phosphorus Magnesium

Recommended Daily Supplements(4)

Multivitamin with iron (prenatal vitamin will have adeq amount of folic acid)

Calcium (citrate) with vitamin D (1200-1500 mg calcium with 800-1000 IU vitamin D)

Oral vitamin B12 (500-1000 mcg) Iron (65 mgday in elemental form)

Vitamin C (to increase absorption of Iron) Thiamin (10 mgday)

Diet Recommendations(3)

Reduce food volume Chew food very well Slow pace of eating No liquids with meals Encourage fruits and vegetables as diet progresses Include high protein foods (at least 60gday) may need protein

supplements

Diet Progression Gastric Bypass

Stage 1 Clear liquids and protein supplement (1 week)

Stage 2No concentrated sweets low fat puree diet ( 3 weeks)

Stage 3 Regular texture weight reduction diet

Diet Progression Lap - Band

Stage 1 Clear liquids and protein supplement ( 2 weeks)

Stage 2 No concentrated sweets low fat puree diet (2weeks)

Stage 3 Regular texture weight reduction diet

Stage 1

Only clear liquids allowed Avoid sweetened beverages Sip very slowly No straws Avoid caffeinated carbonated and alcoholic beverages STOP drinking if you feel fullness pain or discomfort

Protein supplements

Begin the day after you go home from Hospital

Minimum protein target 70gmsday

May use powder or pre-mixed liquid forms (Whey protein is preferred)

Protein pills may not be used

Vitamin and Mineral Supplements

Gastric bypass patients In addition to eating much less food gastric bypass patients will also

absorb vitamins and minerals differently after surgery They will require daily multivitamin calcium and iron

supplementation for the rest of your life

Vitamin and Mineral Supplements

Lap-Bandreg patients

Require a multivitamin with minerals daily

It may be necessary to take additional vitamins and minerals eg calcium iron folateB1 B12These will be prescribed as needed

Stage 2 dietPUREE

Puree diet

Regular scheduled meals Avoid meal skipping Plan meals in advance Eat Slowly Eat protein foods first Moisten meats Use liquid protein as supplement not as meal replacement

Measure 2 oz portions at each meal eating when full Separate liquids and solids No bread rice or pasta Avoid added sugars and high fat

foods VARIETY

The stomach is partitioned along its axis with a non-

adjustable poly-urethane band and with linear amp 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 was practiced in 1980

Vertical Banded Gastroplasty (VBG)

ADJUSTABLE GASTRIC BANDING (LAP BAND SURGERY LAGB)

Restrictive Procedure The procedure was first performed by Cadiere in 1992 but was made popular by Belachew and Legrand in 1993 An inflatable silicone BAND is placed around the top portion of the stomach to form a small stomach pouch amp sewed

This band is connected to a tube that leads to a port above the abdominal muscles placed below the skin (FILL ndash PORT)

During follow up visits we inject or remove saline solution to make the band tighter or looser

Adjustable Gastric Band

bull 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

How does the Band work

Surgery Factors Restriction of meal size Decreased appetite

Patient Factors Decreased calorie intake Increased calorie expenditure

LAP-BAND Adjustability

Unfilled Band Filled Band

Adjustments are made in the office

Complications of Gastric Lap-Band

bull Perforation of Stomachbull Slippagebull Gastric Erosion(much less after Pars flaccida technique) bull Dilated Esophagusbull Tubing access port problemsbull Mal positioningbull Abdominal Painbull Heartburnbull Vomitingbull Inability to Adjust the Bandbull Failure to Lose Weightbull Infection of Systembull Fatigue or malfunction

Advantages

No intestinal surgery No staplingcutting of stomach No nutritional risks Adjustable Reversible Safe

Foreign body Frequent follow-up visits Needs more commitment Easy to cheat

Disadvantages

Comparison of Adjustable Gastric Banding and Vertical Banded Gastroplasty

Laparoscopic adjustable gastric banding Reversible Adjustable Simpler to perform laparoscopically Sustained weight loss of gt50 EBW gt5

years following surgery Complications Gastric prolapse band

erosion rarely gastric perforation and access port complications

Vertical banded gastroplasty Irreversible Non adjustable Technically difficult by laparoscopy Weight loss of 25-50 EBW and weight gain

after 2-3 years Complications suture line disruption gastric

leak weight gain

>

>

Originally used as the first-stage operation for a proposed biliopancreatic diversion with duodenal switch in high-risk patients

The sleeve gastrectomy has caught on as a primary obesity treatment as surgeons are reporting weight loss of 55 of excess body weight past 5 years in some patients

The sleeve gastrectomy is also known as the greater curvature gastrectomy vertical or longitudinal gastrectomy or Pylorus preserving lsquogastric tube creationrsquo

Rapid and less traumatic operation Good resolution of co-morbidities and good weight loss

A further second surgical step is then easily feasible if necessary

SLEEVE GASTRECTOMY

SLEEVE GASTRECTOMY

A sleeve gastrectomy involves resection of

approximately 80 of the greater curvature

side of the stomach

Smaller tubular gastric ldquosleeverdquo created

along the lesser curve that is based on the

lesser curvature blood supply

Ideal approximate capacity of the stomach

after the procedure is about 30- 60 ml pouch

1MECHANICAL RESTRICTION by reducing the volume of the stomach and impairing stomach mobility Also called lsquoFood limitingrsquo operation

2HORMONAL MODIFICATION by removing a great part of the Ghrelin (Hunger Hormone) production tissue

(Ghrelin is a 28 amino-acid-peptide secreted by the oxyntic glands of the gastric fungus It is a potent orexigenic (appetite-stimulating) peptide mediated by the activation of its receptors in the hypothalamus or pituitary area)

The gastric fundus contains 10 to 20 times more ghrelin per one gram of tissue than the duodenum In the SG resection of the fundus removes the major portion of ghrelin release therefore appetite decreases

The sleeve gastrectomy (SG) induces weight loss by 2 mechanisms

>

Intragastric balloon involves placing a deflated balloon into the stomach and then filling it to decrease the amount of gastric space

The balloon can be left in the stomach for a maximum of 6 months and results in an average weight loss of 5ndash9 BMI over half a year

Done endoscopically

The intragastric balloon may be used prior to another bariatric surgery as a step-down procedure

INTRA GASTRIC BALLOON

>

>

The EndoBarrier gastrointestinal liner mimics the effects of gastric bypass surgery

Itrsquos designed to work by inserting a flexible

tube-like barrier into the duodenum amp 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

ENDO BARRIER LINER SYSTEM

B MAL- ABSORPTIVE PROCEDURES

Malabsorptive surgeries rearrange andor remove part of digestive system which then limits the amount of calories and nutrients that body can absorb Treatment with a large malabsorptive component results in the most weight loss but tend to have slightly higher complication rates

1JEJUNAL ILEAL BYPASS ndash no longer performed for high complication rates

2ILEAL TRANSPOSITION- New malabsoptive procedure on trial for treatment of DM type 2 and metabolic disorders

C COMBINATION PROCEDURES RESTRICTIVE + MALABSORBTIVE

1LAP GASTRIC BYPASS ndash ROUX-EN- Y ndash more malabsorption than the restrictive

2MINI- GASTRIC BYPASS- mainly restrictive

3DUODENAL SWITCH ndash the sleeve stomach is the restrictive portion ampthe intestinal bypass (duodenal switch) is the malabsorptive component

When surgery combines both restrictive and malabsorptive techniques it is know as a ldquocombinationrdquo procedure Most types of bariatric surgery carry at least a small element of both components but the following surgeries achieve a notable portion of weight loss from eachhellip

1 LAP GASTRIC BYPASS LGB

The Roux-en-Y gastric bypass(known simply as the LRYGBP) is the most commonly performed procedure

It primarily causesweight loss by restricting thefood intake however there ismore amount of mal absorption that occurs with this operation

GASTRIC BYPASS LRYGBP

bullThe stomach is stapled into2 pieces one small and one large The small piece becomes the ldquonewrdquo stomach pouch

bull The larger portion of the stomach stays in place however will lie dormant for the remainder of the patientrsquos life

GASTRIC BYPASS LGB

bull The small intestine (the jejunum) is divided using a surgical staplerApprox 50-70 cm from the DJ Junction

GASTRIC BYPASS LGB

Y- LIMB BP LIMB

bull The end of the Roux limb is then attached to the newly formed stomach pouch which carries food to the distal intestine

bull The Roux loop is completed by forming a jejunostomy

bull The Y limb or BPD limb carries digestive juices from the pancreas gall bladder liver and duodenum to the intestines

bull The food and the digestive juices mix where the Roux limb and Y limb meet much below say 100-150 cm from DJ

Roux limb or alimentary limb

100-150 cm

How Does the Roux-en-Y Work

Surgery factors restriction of meal size ldquodumping syndromerdquo some malabsorption decreased appetite

Patient factors calorie intake calorie expenditure

bull Most commonly performedbull Most reliable operation for long term weight lossbull Long term weight loss averages 60 to 75 percent of EBWbull Malnutrition is unusualbull Substantial improvement amp resolution in many co-morbid

obesity conditions

ADVANTAGES OF RYGBP

1 Not reversible

2 Mortality 05- 1

3 Perioperative complications 5-10

4 Stricture of gastrojejunostomy-10 (long term)

5 Long term risk of protein amp vitamin deficiency and marginal ulceration of GJA

6Long term risk of intestinal obstruction ndash 2

LAPAROSCOPIC GASTRIC BYPASSCOMPLICATIONS

Biliopancreatic Diversion (BPD)

Primarily malabsorptive but restrictive component also

First Terminal ileum is measured to a length of 50 cms marked with suture

The alimentary tract beyond the proximal part of stomach is rearranged to

include only distal 200 cm of ileum including common channel

Common channel-Distal 50 cm of terminal ileum for absorption of fat and

protein

The proximal end of ileum anastomosed to proximal end of stomach after

performing distal hemigastrectomy

Biliopancreatic Diversion with Duodenal Switch

Modification to lessen high incidence of vit b12 deficiency anastomotic stricture at gastrojejunal anastomosis

This procedure involves a sleeve gastrectomy that is then diverted at the duodenum into the ileum at a point measured proximally from the ileocecal valve (usually 250 cm)

The distal duodenum and jejunum the biliopancreatic limb are then anastomosed to the ileum at a point measured proximally from the ileocecal valve (usually 100 cm)

Common channel is 100cm Entire alimentary tract is 250 cm This is the most aggressive bypass procedure commonly offered today Major difference-Sleeve gastrectomy instead of distal hemigastrectomy

bull Most women regained normal menstrual function and most had documented

spontaneous ovulation

bull Significant improvement in hirsutism androgen profiles and about a 50 reduction in

HOMA-IR

bull Follow up for more than 2 years showed that all women resumed normal menstrual

cycles HbA1C decreased from 82 to 51 in lt 3 months

bull 78 saw improvement in metabolic syndrome amp 48 showed improvement in PCOS

2 ROLE OF BARIATRIC SURGERY IN PCOS PATIENTS

bull Decrease menstrual irregularities bull PCOS women have less hyper androgenism

bull Sex hormone binding globulin increases bull LH and FSH levels have been reported to increase

bull Ovulatory function measured by luteal LH and Progesterone secretion improved bull Leptin levels decrease reflecting improved reproductive metabolic status

bull Subclinical hypothyroidism significantly reduced

THE SAFE TIMING OF PREGNANCYoptimal or minimal time gt12 months after bariatric surgery before becoming pregnant in order to allow the rapid weight loss and metabolic changes to subside

4 BARIATRIC SURGERY IN REPRODUCTIVE WOMEN

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)

The foregut hypothesis theory ndash 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

Effect of Bariatric Surgery on Diabetes Mellitus

Combined Gastric Restriction amp Malabsorption

Operative Risks (vs cholecystectomy)

Perioperative Mortality 1-2 vs 02-08 Early Complications 10 vs 29Late Complications 20 vs 1-2

LimitationsWidening of (unbanded) gastrojejunostomyExpansion of gastric pouch 25 with nearly 100 weight regainAdaptation of limb that receives the food

SUMMARY OF ALL TYPES OF SURGERY

bull LRYGBP ndash worlds best procedure 60-70 WL dumping syndrome malnutrition

bull LAGB- low complications varying range of wt loss frequent post-op visits ( 10)

bull DSBPD- more wt loss high complications good for high BMI gt 50 malabsorption +

bull VBG(vertical band gastroplasty) ndash longest available results good wt loss improved co-morbidities right for some ptsrisks too high to justify rewards

bull SG- needs long term research 1st step procedure low risks higher wt loss lesser complications pouch could Stretch over time long staple line could cause problems in future frequency is accelerating because of technical ease 1st stage procedure before bypass

Post-surgical Complications

Anastomosis leaks or staple line leaks Pulmonary Embolism or DVT Cholelithiasis Stomal ulceration Dumping syndrome Constipation

Anastamosis Leaks

Up to 7-10 days after surgery Most common at gastrojejunostomy enteroenterostomy Roux

limb stump staple line Can lead to peritonitis sepsis possible death Presentation

Tachycardia tachypnea Fever Ab painback pain Pelvic pressure or rebound tenderness

Anastamosis Leaks

Order Gastrograffin upper GI series Subclinical cases

Bowel rest Parenteral nutrition IV antibiotic if H pylori

Clinically suspect leak Laparoscopic evaluation and leak repair

Failure to evaluate is the most common cause of preventable major long-term disability or death in bariatric surgical patients

Pulmonary Embolism

Sudden cause of death up to one month after surgery 20-30 mortality rate High risk may have vena cava filter placement prior to surgery Prophylaxis with compression stockings and LMWH Early ambulation imperitive

Pulmonary Embolism

Presentation Profound hypoxia Hypotension Signs of sepsis

Immediate spiral chest CT Abdominal exploration if too large for machine No pathology start anticoagulation Too largehelliphellipNO SURGERY

Cholelithiasis

Up to 36 of patients within 6 months post-op Bile stasis leads to increased sludge and gallstones Prophylactic cholecystectomy prior to surgery if

evidence of existing sludge or stones Prevent post-operative disease with concurrent bariatric

surgery and cholecystectomy Prophylactic use of urosidol

Expensive and unpalatable

Stomal Ulceration

12-15 within 2-4 mos Post-surgery Etiology

Overabundant acid in pouch leads to excessive acid passing through stoma

Pouch tension and staple line breakdown NSAID use

Presentation Dyspepsia vomiting Epigastric or retrosternal pain

Stomal Ulceration

Treatment PPI carafate Antibiotics if H Pylori Avoid NSAIDS alcohol smoking

If no response to treatment Endoscopy Back to surgery for pouch revision or staple line repair

Dumping Syndrome

More than 15 patients Hypotention Tachycardia Lightheadedness syncope Flushing Abdominal cramping and diarrhea Nausea and vomiting

Dumping Syndrome

Occurs with high dose simple sugar ingestion Sugar in small intestine causes osmotic overload and fluid

shift from blood to intestine Increased intestinal volume leads to watery diarrhea Decreased blood volume leads to systemic changes Patient education

Eat slowly Avoid drinking before during and not until 30 minutes after meals

Constipation

Most common complaint Causes

Dehydration and decreased fluid intake post-operatively Increased metabolic water needs Calcium and iron supplement use following surgery

Treat with increased fluids and stool softeners

Nutritional Consequences

Iron deficiency anemia B12 deficiency Folate deficiency Calcium and Vitamin D deficiency

Not seen with purely restrictive surgeries

Iron deficiency and anemia

Common following RYGB As high as 49 of patients Multifactorial cause

Low gastric acid levels prohibit iron cleavage from food Absorption inhibited because no nutrient exposure to duodenum or

proximal jejunum Decrease in iron-rich food consumption due to intolerance

Treat with oral supplementation of ferrous sulfate or ferrous gluconate

Vitamin B12 deficiency

Up to 70 of patients Lack of hydrochloric acid and pepsin in stomach

Prevents B12 cleavage from food Affects secretion of intrinsic factor thus B12 absorption

Intolerance to meat and milk Oral supplementation usually adequate otherwise IM injections used

Folate Deficiency

40 of gastric bypass patients Complete absorption requires B12 Absorption dependent on HCl and upper 13 stomach Deficiency generally caused by decreased consumption Oral supplementation

Vitamin D and Calcium Deficiency

Vitamin D deficiency is common among obese people Calcium absorption decreased because duodenum is

bypassed Intolerance to dairy foods high in calcium Vitamin D is required for Ca++ absorption Prolonged deficiencies lead to

Bone resorption osteomalacia osteoporosis Treat with calcium citrate supplementation and 2 weekly

doses of Vitamin D

Nutritional Implications of Various Bariatric Surgeries(34)

bull RYGB Malabsorption of Vit B12 Vit B1 (thiamin) Vit D Vit K Folate Iron Calcium

bull LAGB Folic Acid deficiency

bull BPD and BPDDS Vit A D E and K deficiency Protein-Calorie Malnutrition Malabsorption of

Calcium Zinc Selenium Sodium Potassium Chloride Phosphorus Magnesium

Recommended Daily Supplements(4)

Multivitamin with iron (prenatal vitamin will have adeq amount of folic acid)

Calcium (citrate) with vitamin D (1200-1500 mg calcium with 800-1000 IU vitamin D)

Oral vitamin B12 (500-1000 mcg) Iron (65 mgday in elemental form)

Vitamin C (to increase absorption of Iron) Thiamin (10 mgday)

Diet Recommendations(3)

Reduce food volume Chew food very well Slow pace of eating No liquids with meals Encourage fruits and vegetables as diet progresses Include high protein foods (at least 60gday) may need protein

supplements

Diet Progression Gastric Bypass

Stage 1 Clear liquids and protein supplement (1 week)

Stage 2No concentrated sweets low fat puree diet ( 3 weeks)

Stage 3 Regular texture weight reduction diet

Diet Progression Lap - Band

Stage 1 Clear liquids and protein supplement ( 2 weeks)

Stage 2 No concentrated sweets low fat puree diet (2weeks)

Stage 3 Regular texture weight reduction diet

Stage 1

Only clear liquids allowed Avoid sweetened beverages Sip very slowly No straws Avoid caffeinated carbonated and alcoholic beverages STOP drinking if you feel fullness pain or discomfort

Protein supplements

Begin the day after you go home from Hospital

Minimum protein target 70gmsday

May use powder or pre-mixed liquid forms (Whey protein is preferred)

Protein pills may not be used

Vitamin and Mineral Supplements

Gastric bypass patients In addition to eating much less food gastric bypass patients will also

absorb vitamins and minerals differently after surgery They will require daily multivitamin calcium and iron

supplementation for the rest of your life

Vitamin and Mineral Supplements

Lap-Bandreg patients

Require a multivitamin with minerals daily

It may be necessary to take additional vitamins and minerals eg calcium iron folateB1 B12These will be prescribed as needed

Stage 2 dietPUREE

Puree diet

Regular scheduled meals Avoid meal skipping Plan meals in advance Eat Slowly Eat protein foods first Moisten meats Use liquid protein as supplement not as meal replacement

Measure 2 oz portions at each meal eating when full Separate liquids and solids No bread rice or pasta Avoid added sugars and high fat

foods VARIETY

ADJUSTABLE GASTRIC BANDING (LAP BAND SURGERY LAGB)

Restrictive Procedure The procedure was first performed by Cadiere in 1992 but was made popular by Belachew and Legrand in 1993 An inflatable silicone BAND is placed around the top portion of the stomach to form a small stomach pouch amp sewed

This band is connected to a tube that leads to a port above the abdominal muscles placed below the skin (FILL ndash PORT)

During follow up visits we inject or remove saline solution to make the band tighter or looser

Adjustable Gastric Band

bull 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

How does the Band work

Surgery Factors Restriction of meal size Decreased appetite

Patient Factors Decreased calorie intake Increased calorie expenditure

LAP-BAND Adjustability

Unfilled Band Filled Band

Adjustments are made in the office

Complications of Gastric Lap-Band

bull Perforation of Stomachbull Slippagebull Gastric Erosion(much less after Pars flaccida technique) bull Dilated Esophagusbull Tubing access port problemsbull Mal positioningbull Abdominal Painbull Heartburnbull Vomitingbull Inability to Adjust the Bandbull Failure to Lose Weightbull Infection of Systembull Fatigue or malfunction

Advantages

No intestinal surgery No staplingcutting of stomach No nutritional risks Adjustable Reversible Safe

Foreign body Frequent follow-up visits Needs more commitment Easy to cheat

Disadvantages

Comparison of Adjustable Gastric Banding and Vertical Banded Gastroplasty

Laparoscopic adjustable gastric banding Reversible Adjustable Simpler to perform laparoscopically Sustained weight loss of gt50 EBW gt5

years following surgery Complications Gastric prolapse band

erosion rarely gastric perforation and access port complications

Vertical banded gastroplasty Irreversible Non adjustable Technically difficult by laparoscopy Weight loss of 25-50 EBW and weight gain

after 2-3 years Complications suture line disruption gastric

leak weight gain

>

>

Originally used as the first-stage operation for a proposed biliopancreatic diversion with duodenal switch in high-risk patients

The sleeve gastrectomy has caught on as a primary obesity treatment as surgeons are reporting weight loss of 55 of excess body weight past 5 years in some patients

The sleeve gastrectomy is also known as the greater curvature gastrectomy vertical or longitudinal gastrectomy or Pylorus preserving lsquogastric tube creationrsquo

Rapid and less traumatic operation Good resolution of co-morbidities and good weight loss

A further second surgical step is then easily feasible if necessary

SLEEVE GASTRECTOMY

SLEEVE GASTRECTOMY

A sleeve gastrectomy involves resection of

approximately 80 of the greater curvature

side of the stomach

Smaller tubular gastric ldquosleeverdquo created

along the lesser curve that is based on the

lesser curvature blood supply

Ideal approximate capacity of the stomach

after the procedure is about 30- 60 ml pouch

1MECHANICAL RESTRICTION by reducing the volume of the stomach and impairing stomach mobility Also called lsquoFood limitingrsquo operation

2HORMONAL MODIFICATION by removing a great part of the Ghrelin (Hunger Hormone) production tissue

(Ghrelin is a 28 amino-acid-peptide secreted by the oxyntic glands of the gastric fungus It is a potent orexigenic (appetite-stimulating) peptide mediated by the activation of its receptors in the hypothalamus or pituitary area)

The gastric fundus contains 10 to 20 times more ghrelin per one gram of tissue than the duodenum In the SG resection of the fundus removes the major portion of ghrelin release therefore appetite decreases

The sleeve gastrectomy (SG) induces weight loss by 2 mechanisms

>

Intragastric balloon involves placing a deflated balloon into the stomach and then filling it to decrease the amount of gastric space

The balloon can be left in the stomach for a maximum of 6 months and results in an average weight loss of 5ndash9 BMI over half a year

Done endoscopically

The intragastric balloon may be used prior to another bariatric surgery as a step-down procedure

INTRA GASTRIC BALLOON

>

>

The EndoBarrier gastrointestinal liner mimics the effects of gastric bypass surgery

Itrsquos designed to work by inserting a flexible

tube-like barrier into the duodenum amp 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

ENDO BARRIER LINER SYSTEM

B MAL- ABSORPTIVE PROCEDURES

Malabsorptive surgeries rearrange andor remove part of digestive system which then limits the amount of calories and nutrients that body can absorb Treatment with a large malabsorptive component results in the most weight loss but tend to have slightly higher complication rates

1JEJUNAL ILEAL BYPASS ndash no longer performed for high complication rates

2ILEAL TRANSPOSITION- New malabsoptive procedure on trial for treatment of DM type 2 and metabolic disorders

C COMBINATION PROCEDURES RESTRICTIVE + MALABSORBTIVE

1LAP GASTRIC BYPASS ndash ROUX-EN- Y ndash more malabsorption than the restrictive

2MINI- GASTRIC BYPASS- mainly restrictive

3DUODENAL SWITCH ndash the sleeve stomach is the restrictive portion ampthe intestinal bypass (duodenal switch) is the malabsorptive component

When surgery combines both restrictive and malabsorptive techniques it is know as a ldquocombinationrdquo procedure Most types of bariatric surgery carry at least a small element of both components but the following surgeries achieve a notable portion of weight loss from eachhellip

1 LAP GASTRIC BYPASS LGB

The Roux-en-Y gastric bypass(known simply as the LRYGBP) is the most commonly performed procedure

It primarily causesweight loss by restricting thefood intake however there ismore amount of mal absorption that occurs with this operation

GASTRIC BYPASS LRYGBP

bullThe stomach is stapled into2 pieces one small and one large The small piece becomes the ldquonewrdquo stomach pouch

bull The larger portion of the stomach stays in place however will lie dormant for the remainder of the patientrsquos life

GASTRIC BYPASS LGB

bull The small intestine (the jejunum) is divided using a surgical staplerApprox 50-70 cm from the DJ Junction

GASTRIC BYPASS LGB

Y- LIMB BP LIMB

bull The end of the Roux limb is then attached to the newly formed stomach pouch which carries food to the distal intestine

bull The Roux loop is completed by forming a jejunostomy

bull The Y limb or BPD limb carries digestive juices from the pancreas gall bladder liver and duodenum to the intestines

bull The food and the digestive juices mix where the Roux limb and Y limb meet much below say 100-150 cm from DJ

Roux limb or alimentary limb

100-150 cm

How Does the Roux-en-Y Work

Surgery factors restriction of meal size ldquodumping syndromerdquo some malabsorption decreased appetite

Patient factors calorie intake calorie expenditure

bull Most commonly performedbull Most reliable operation for long term weight lossbull Long term weight loss averages 60 to 75 percent of EBWbull Malnutrition is unusualbull Substantial improvement amp resolution in many co-morbid

obesity conditions

ADVANTAGES OF RYGBP

1 Not reversible

2 Mortality 05- 1

3 Perioperative complications 5-10

4 Stricture of gastrojejunostomy-10 (long term)

5 Long term risk of protein amp vitamin deficiency and marginal ulceration of GJA

6Long term risk of intestinal obstruction ndash 2

LAPAROSCOPIC GASTRIC BYPASSCOMPLICATIONS

Biliopancreatic Diversion (BPD)

Primarily malabsorptive but restrictive component also

First Terminal ileum is measured to a length of 50 cms marked with suture

The alimentary tract beyond the proximal part of stomach is rearranged to

include only distal 200 cm of ileum including common channel

Common channel-Distal 50 cm of terminal ileum for absorption of fat and

protein

The proximal end of ileum anastomosed to proximal end of stomach after

performing distal hemigastrectomy

Biliopancreatic Diversion with Duodenal Switch

Modification to lessen high incidence of vit b12 deficiency anastomotic stricture at gastrojejunal anastomosis

This procedure involves a sleeve gastrectomy that is then diverted at the duodenum into the ileum at a point measured proximally from the ileocecal valve (usually 250 cm)

The distal duodenum and jejunum the biliopancreatic limb are then anastomosed to the ileum at a point measured proximally from the ileocecal valve (usually 100 cm)

Common channel is 100cm Entire alimentary tract is 250 cm This is the most aggressive bypass procedure commonly offered today Major difference-Sleeve gastrectomy instead of distal hemigastrectomy

bull Most women regained normal menstrual function and most had documented

spontaneous ovulation

bull Significant improvement in hirsutism androgen profiles and about a 50 reduction in

HOMA-IR

bull Follow up for more than 2 years showed that all women resumed normal menstrual

cycles HbA1C decreased from 82 to 51 in lt 3 months

bull 78 saw improvement in metabolic syndrome amp 48 showed improvement in PCOS

2 ROLE OF BARIATRIC SURGERY IN PCOS PATIENTS

bull Decrease menstrual irregularities bull PCOS women have less hyper androgenism

bull Sex hormone binding globulin increases bull LH and FSH levels have been reported to increase

bull Ovulatory function measured by luteal LH and Progesterone secretion improved bull Leptin levels decrease reflecting improved reproductive metabolic status

bull Subclinical hypothyroidism significantly reduced

THE SAFE TIMING OF PREGNANCYoptimal or minimal time gt12 months after bariatric surgery before becoming pregnant in order to allow the rapid weight loss and metabolic changes to subside

4 BARIATRIC SURGERY IN REPRODUCTIVE WOMEN

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)

The foregut hypothesis theory ndash 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

Effect of Bariatric Surgery on Diabetes Mellitus

Combined Gastric Restriction amp Malabsorption

Operative Risks (vs cholecystectomy)

Perioperative Mortality 1-2 vs 02-08 Early Complications 10 vs 29Late Complications 20 vs 1-2

LimitationsWidening of (unbanded) gastrojejunostomyExpansion of gastric pouch 25 with nearly 100 weight regainAdaptation of limb that receives the food

SUMMARY OF ALL TYPES OF SURGERY

bull LRYGBP ndash worlds best procedure 60-70 WL dumping syndrome malnutrition

bull LAGB- low complications varying range of wt loss frequent post-op visits ( 10)

bull DSBPD- more wt loss high complications good for high BMI gt 50 malabsorption +

bull VBG(vertical band gastroplasty) ndash longest available results good wt loss improved co-morbidities right for some ptsrisks too high to justify rewards

bull SG- needs long term research 1st step procedure low risks higher wt loss lesser complications pouch could Stretch over time long staple line could cause problems in future frequency is accelerating because of technical ease 1st stage procedure before bypass

Post-surgical Complications

Anastomosis leaks or staple line leaks Pulmonary Embolism or DVT Cholelithiasis Stomal ulceration Dumping syndrome Constipation

Anastamosis Leaks

Up to 7-10 days after surgery Most common at gastrojejunostomy enteroenterostomy Roux

limb stump staple line Can lead to peritonitis sepsis possible death Presentation

Tachycardia tachypnea Fever Ab painback pain Pelvic pressure or rebound tenderness

Anastamosis Leaks

Order Gastrograffin upper GI series Subclinical cases

Bowel rest Parenteral nutrition IV antibiotic if H pylori

Clinically suspect leak Laparoscopic evaluation and leak repair

Failure to evaluate is the most common cause of preventable major long-term disability or death in bariatric surgical patients

Pulmonary Embolism

Sudden cause of death up to one month after surgery 20-30 mortality rate High risk may have vena cava filter placement prior to surgery Prophylaxis with compression stockings and LMWH Early ambulation imperitive

Pulmonary Embolism

Presentation Profound hypoxia Hypotension Signs of sepsis

Immediate spiral chest CT Abdominal exploration if too large for machine No pathology start anticoagulation Too largehelliphellipNO SURGERY

Cholelithiasis

Up to 36 of patients within 6 months post-op Bile stasis leads to increased sludge and gallstones Prophylactic cholecystectomy prior to surgery if

evidence of existing sludge or stones Prevent post-operative disease with concurrent bariatric

surgery and cholecystectomy Prophylactic use of urosidol

Expensive and unpalatable

Stomal Ulceration

12-15 within 2-4 mos Post-surgery Etiology

Overabundant acid in pouch leads to excessive acid passing through stoma

Pouch tension and staple line breakdown NSAID use

Presentation Dyspepsia vomiting Epigastric or retrosternal pain

Stomal Ulceration

Treatment PPI carafate Antibiotics if H Pylori Avoid NSAIDS alcohol smoking

If no response to treatment Endoscopy Back to surgery for pouch revision or staple line repair

Dumping Syndrome

More than 15 patients Hypotention Tachycardia Lightheadedness syncope Flushing Abdominal cramping and diarrhea Nausea and vomiting

Dumping Syndrome

Occurs with high dose simple sugar ingestion Sugar in small intestine causes osmotic overload and fluid

shift from blood to intestine Increased intestinal volume leads to watery diarrhea Decreased blood volume leads to systemic changes Patient education

Eat slowly Avoid drinking before during and not until 30 minutes after meals

Constipation

Most common complaint Causes

Dehydration and decreased fluid intake post-operatively Increased metabolic water needs Calcium and iron supplement use following surgery

Treat with increased fluids and stool softeners

Nutritional Consequences

Iron deficiency anemia B12 deficiency Folate deficiency Calcium and Vitamin D deficiency

Not seen with purely restrictive surgeries

Iron deficiency and anemia

Common following RYGB As high as 49 of patients Multifactorial cause

Low gastric acid levels prohibit iron cleavage from food Absorption inhibited because no nutrient exposure to duodenum or

proximal jejunum Decrease in iron-rich food consumption due to intolerance

Treat with oral supplementation of ferrous sulfate or ferrous gluconate

Vitamin B12 deficiency

Up to 70 of patients Lack of hydrochloric acid and pepsin in stomach

Prevents B12 cleavage from food Affects secretion of intrinsic factor thus B12 absorption

Intolerance to meat and milk Oral supplementation usually adequate otherwise IM injections used

Folate Deficiency

40 of gastric bypass patients Complete absorption requires B12 Absorption dependent on HCl and upper 13 stomach Deficiency generally caused by decreased consumption Oral supplementation

Vitamin D and Calcium Deficiency

Vitamin D deficiency is common among obese people Calcium absorption decreased because duodenum is

bypassed Intolerance to dairy foods high in calcium Vitamin D is required for Ca++ absorption Prolonged deficiencies lead to

Bone resorption osteomalacia osteoporosis Treat with calcium citrate supplementation and 2 weekly

doses of Vitamin D

Nutritional Implications of Various Bariatric Surgeries(34)

bull RYGB Malabsorption of Vit B12 Vit B1 (thiamin) Vit D Vit K Folate Iron Calcium

bull LAGB Folic Acid deficiency

bull BPD and BPDDS Vit A D E and K deficiency Protein-Calorie Malnutrition Malabsorption of

Calcium Zinc Selenium Sodium Potassium Chloride Phosphorus Magnesium

Recommended Daily Supplements(4)

Multivitamin with iron (prenatal vitamin will have adeq amount of folic acid)

Calcium (citrate) with vitamin D (1200-1500 mg calcium with 800-1000 IU vitamin D)

Oral vitamin B12 (500-1000 mcg) Iron (65 mgday in elemental form)

Vitamin C (to increase absorption of Iron) Thiamin (10 mgday)

Diet Recommendations(3)

Reduce food volume Chew food very well Slow pace of eating No liquids with meals Encourage fruits and vegetables as diet progresses Include high protein foods (at least 60gday) may need protein

supplements

Diet Progression Gastric Bypass

Stage 1 Clear liquids and protein supplement (1 week)

Stage 2No concentrated sweets low fat puree diet ( 3 weeks)

Stage 3 Regular texture weight reduction diet

Diet Progression Lap - Band

Stage 1 Clear liquids and protein supplement ( 2 weeks)

Stage 2 No concentrated sweets low fat puree diet (2weeks)

Stage 3 Regular texture weight reduction diet

Stage 1

Only clear liquids allowed Avoid sweetened beverages Sip very slowly No straws Avoid caffeinated carbonated and alcoholic beverages STOP drinking if you feel fullness pain or discomfort

Protein supplements

Begin the day after you go home from Hospital

Minimum protein target 70gmsday

May use powder or pre-mixed liquid forms (Whey protein is preferred)

Protein pills may not be used

Vitamin and Mineral Supplements

Gastric bypass patients In addition to eating much less food gastric bypass patients will also

absorb vitamins and minerals differently after surgery They will require daily multivitamin calcium and iron

supplementation for the rest of your life

Vitamin and Mineral Supplements

Lap-Bandreg patients

Require a multivitamin with minerals daily

It may be necessary to take additional vitamins and minerals eg calcium iron folateB1 B12These will be prescribed as needed

Stage 2 dietPUREE

Puree diet

Regular scheduled meals Avoid meal skipping Plan meals in advance Eat Slowly Eat protein foods first Moisten meats Use liquid protein as supplement not as meal replacement

Measure 2 oz portions at each meal eating when full Separate liquids and solids No bread rice or pasta Avoid added sugars and high fat

foods VARIETY

Adjustable Gastric Band

bull 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

How does the Band work

Surgery Factors Restriction of meal size Decreased appetite

Patient Factors Decreased calorie intake Increased calorie expenditure

LAP-BAND Adjustability

Unfilled Band Filled Band

Adjustments are made in the office

Complications of Gastric Lap-Band

bull Perforation of Stomachbull Slippagebull Gastric Erosion(much less after Pars flaccida technique) bull Dilated Esophagusbull Tubing access port problemsbull Mal positioningbull Abdominal Painbull Heartburnbull Vomitingbull Inability to Adjust the Bandbull Failure to Lose Weightbull Infection of Systembull Fatigue or malfunction

Advantages

No intestinal surgery No staplingcutting of stomach No nutritional risks Adjustable Reversible Safe

Foreign body Frequent follow-up visits Needs more commitment Easy to cheat

Disadvantages

Comparison of Adjustable Gastric Banding and Vertical Banded Gastroplasty

Laparoscopic adjustable gastric banding Reversible Adjustable Simpler to perform laparoscopically Sustained weight loss of gt50 EBW gt5

years following surgery Complications Gastric prolapse band

erosion rarely gastric perforation and access port complications

Vertical banded gastroplasty Irreversible Non adjustable Technically difficult by laparoscopy Weight loss of 25-50 EBW and weight gain

after 2-3 years Complications suture line disruption gastric

leak weight gain

>

>

Originally used as the first-stage operation for a proposed biliopancreatic diversion with duodenal switch in high-risk patients

The sleeve gastrectomy has caught on as a primary obesity treatment as surgeons are reporting weight loss of 55 of excess body weight past 5 years in some patients

The sleeve gastrectomy is also known as the greater curvature gastrectomy vertical or longitudinal gastrectomy or Pylorus preserving lsquogastric tube creationrsquo

Rapid and less traumatic operation Good resolution of co-morbidities and good weight loss

A further second surgical step is then easily feasible if necessary

SLEEVE GASTRECTOMY

SLEEVE GASTRECTOMY

A sleeve gastrectomy involves resection of

approximately 80 of the greater curvature

side of the stomach

Smaller tubular gastric ldquosleeverdquo created

along the lesser curve that is based on the

lesser curvature blood supply

Ideal approximate capacity of the stomach

after the procedure is about 30- 60 ml pouch

1MECHANICAL RESTRICTION by reducing the volume of the stomach and impairing stomach mobility Also called lsquoFood limitingrsquo operation

2HORMONAL MODIFICATION by removing a great part of the Ghrelin (Hunger Hormone) production tissue

(Ghrelin is a 28 amino-acid-peptide secreted by the oxyntic glands of the gastric fungus It is a potent orexigenic (appetite-stimulating) peptide mediated by the activation of its receptors in the hypothalamus or pituitary area)

The gastric fundus contains 10 to 20 times more ghrelin per one gram of tissue than the duodenum In the SG resection of the fundus removes the major portion of ghrelin release therefore appetite decreases

The sleeve gastrectomy (SG) induces weight loss by 2 mechanisms

>

Intragastric balloon involves placing a deflated balloon into the stomach and then filling it to decrease the amount of gastric space

The balloon can be left in the stomach for a maximum of 6 months and results in an average weight loss of 5ndash9 BMI over half a year

Done endoscopically

The intragastric balloon may be used prior to another bariatric surgery as a step-down procedure

INTRA GASTRIC BALLOON

>

>

The EndoBarrier gastrointestinal liner mimics the effects of gastric bypass surgery

Itrsquos designed to work by inserting a flexible

tube-like barrier into the duodenum amp 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

ENDO BARRIER LINER SYSTEM

B MAL- ABSORPTIVE PROCEDURES

Malabsorptive surgeries rearrange andor remove part of digestive system which then limits the amount of calories and nutrients that body can absorb Treatment with a large malabsorptive component results in the most weight loss but tend to have slightly higher complication rates

1JEJUNAL ILEAL BYPASS ndash no longer performed for high complication rates

2ILEAL TRANSPOSITION- New malabsoptive procedure on trial for treatment of DM type 2 and metabolic disorders

C COMBINATION PROCEDURES RESTRICTIVE + MALABSORBTIVE

1LAP GASTRIC BYPASS ndash ROUX-EN- Y ndash more malabsorption than the restrictive

2MINI- GASTRIC BYPASS- mainly restrictive

3DUODENAL SWITCH ndash the sleeve stomach is the restrictive portion ampthe intestinal bypass (duodenal switch) is the malabsorptive component

When surgery combines both restrictive and malabsorptive techniques it is know as a ldquocombinationrdquo procedure Most types of bariatric surgery carry at least a small element of both components but the following surgeries achieve a notable portion of weight loss from eachhellip

1 LAP GASTRIC BYPASS LGB

The Roux-en-Y gastric bypass(known simply as the LRYGBP) is the most commonly performed procedure

It primarily causesweight loss by restricting thefood intake however there ismore amount of mal absorption that occurs with this operation

GASTRIC BYPASS LRYGBP

bullThe stomach is stapled into2 pieces one small and one large The small piece becomes the ldquonewrdquo stomach pouch

bull The larger portion of the stomach stays in place however will lie dormant for the remainder of the patientrsquos life

GASTRIC BYPASS LGB

bull The small intestine (the jejunum) is divided using a surgical staplerApprox 50-70 cm from the DJ Junction

GASTRIC BYPASS LGB

Y- LIMB BP LIMB

bull The end of the Roux limb is then attached to the newly formed stomach pouch which carries food to the distal intestine

bull The Roux loop is completed by forming a jejunostomy

bull The Y limb or BPD limb carries digestive juices from the pancreas gall bladder liver and duodenum to the intestines

bull The food and the digestive juices mix where the Roux limb and Y limb meet much below say 100-150 cm from DJ

Roux limb or alimentary limb

100-150 cm

How Does the Roux-en-Y Work

Surgery factors restriction of meal size ldquodumping syndromerdquo some malabsorption decreased appetite

Patient factors calorie intake calorie expenditure

bull Most commonly performedbull Most reliable operation for long term weight lossbull Long term weight loss averages 60 to 75 percent of EBWbull Malnutrition is unusualbull Substantial improvement amp resolution in many co-morbid

obesity conditions

ADVANTAGES OF RYGBP

1 Not reversible

2 Mortality 05- 1

3 Perioperative complications 5-10

4 Stricture of gastrojejunostomy-10 (long term)

5 Long term risk of protein amp vitamin deficiency and marginal ulceration of GJA

6Long term risk of intestinal obstruction ndash 2

LAPAROSCOPIC GASTRIC BYPASSCOMPLICATIONS

Biliopancreatic Diversion (BPD)

Primarily malabsorptive but restrictive component also

First Terminal ileum is measured to a length of 50 cms marked with suture

The alimentary tract beyond the proximal part of stomach is rearranged to

include only distal 200 cm of ileum including common channel

Common channel-Distal 50 cm of terminal ileum for absorption of fat and

protein

The proximal end of ileum anastomosed to proximal end of stomach after

performing distal hemigastrectomy

Biliopancreatic Diversion with Duodenal Switch

Modification to lessen high incidence of vit b12 deficiency anastomotic stricture at gastrojejunal anastomosis

This procedure involves a sleeve gastrectomy that is then diverted at the duodenum into the ileum at a point measured proximally from the ileocecal valve (usually 250 cm)

The distal duodenum and jejunum the biliopancreatic limb are then anastomosed to the ileum at a point measured proximally from the ileocecal valve (usually 100 cm)

Common channel is 100cm Entire alimentary tract is 250 cm This is the most aggressive bypass procedure commonly offered today Major difference-Sleeve gastrectomy instead of distal hemigastrectomy

bull Most women regained normal menstrual function and most had documented

spontaneous ovulation

bull Significant improvement in hirsutism androgen profiles and about a 50 reduction in

HOMA-IR

bull Follow up for more than 2 years showed that all women resumed normal menstrual

cycles HbA1C decreased from 82 to 51 in lt 3 months

bull 78 saw improvement in metabolic syndrome amp 48 showed improvement in PCOS

2 ROLE OF BARIATRIC SURGERY IN PCOS PATIENTS

bull Decrease menstrual irregularities bull PCOS women have less hyper androgenism

bull Sex hormone binding globulin increases bull LH and FSH levels have been reported to increase

bull Ovulatory function measured by luteal LH and Progesterone secretion improved bull Leptin levels decrease reflecting improved reproductive metabolic status

bull Subclinical hypothyroidism significantly reduced

THE SAFE TIMING OF PREGNANCYoptimal or minimal time gt12 months after bariatric surgery before becoming pregnant in order to allow the rapid weight loss and metabolic changes to subside

4 BARIATRIC SURGERY IN REPRODUCTIVE WOMEN

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)

The foregut hypothesis theory ndash 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

Effect of Bariatric Surgery on Diabetes Mellitus

Combined Gastric Restriction amp Malabsorption

Operative Risks (vs cholecystectomy)

Perioperative Mortality 1-2 vs 02-08 Early Complications 10 vs 29Late Complications 20 vs 1-2

LimitationsWidening of (unbanded) gastrojejunostomyExpansion of gastric pouch 25 with nearly 100 weight regainAdaptation of limb that receives the food

SUMMARY OF ALL TYPES OF SURGERY

bull LRYGBP ndash worlds best procedure 60-70 WL dumping syndrome malnutrition

bull LAGB- low complications varying range of wt loss frequent post-op visits ( 10)

bull DSBPD- more wt loss high complications good for high BMI gt 50 malabsorption +

bull VBG(vertical band gastroplasty) ndash longest available results good wt loss improved co-morbidities right for some ptsrisks too high to justify rewards

bull SG- needs long term research 1st step procedure low risks higher wt loss lesser complications pouch could Stretch over time long staple line could cause problems in future frequency is accelerating because of technical ease 1st stage procedure before bypass

Post-surgical Complications

Anastomosis leaks or staple line leaks Pulmonary Embolism or DVT Cholelithiasis Stomal ulceration Dumping syndrome Constipation

Anastamosis Leaks

Up to 7-10 days after surgery Most common at gastrojejunostomy enteroenterostomy Roux

limb stump staple line Can lead to peritonitis sepsis possible death Presentation

Tachycardia tachypnea Fever Ab painback pain Pelvic pressure or rebound tenderness

Anastamosis Leaks

Order Gastrograffin upper GI series Subclinical cases

Bowel rest Parenteral nutrition IV antibiotic if H pylori

Clinically suspect leak Laparoscopic evaluation and leak repair

Failure to evaluate is the most common cause of preventable major long-term disability or death in bariatric surgical patients

Pulmonary Embolism

Sudden cause of death up to one month after surgery 20-30 mortality rate High risk may have vena cava filter placement prior to surgery Prophylaxis with compression stockings and LMWH Early ambulation imperitive

Pulmonary Embolism

Presentation Profound hypoxia Hypotension Signs of sepsis

Immediate spiral chest CT Abdominal exploration if too large for machine No pathology start anticoagulation Too largehelliphellipNO SURGERY

Cholelithiasis

Up to 36 of patients within 6 months post-op Bile stasis leads to increased sludge and gallstones Prophylactic cholecystectomy prior to surgery if

evidence of existing sludge or stones Prevent post-operative disease with concurrent bariatric

surgery and cholecystectomy Prophylactic use of urosidol

Expensive and unpalatable

Stomal Ulceration

12-15 within 2-4 mos Post-surgery Etiology

Overabundant acid in pouch leads to excessive acid passing through stoma

Pouch tension and staple line breakdown NSAID use

Presentation Dyspepsia vomiting Epigastric or retrosternal pain

Stomal Ulceration

Treatment PPI carafate Antibiotics if H Pylori Avoid NSAIDS alcohol smoking

If no response to treatment Endoscopy Back to surgery for pouch revision or staple line repair

Dumping Syndrome

More than 15 patients Hypotention Tachycardia Lightheadedness syncope Flushing Abdominal cramping and diarrhea Nausea and vomiting

Dumping Syndrome

Occurs with high dose simple sugar ingestion Sugar in small intestine causes osmotic overload and fluid

shift from blood to intestine Increased intestinal volume leads to watery diarrhea Decreased blood volume leads to systemic changes Patient education

Eat slowly Avoid drinking before during and not until 30 minutes after meals

Constipation

Most common complaint Causes

Dehydration and decreased fluid intake post-operatively Increased metabolic water needs Calcium and iron supplement use following surgery

Treat with increased fluids and stool softeners

Nutritional Consequences

Iron deficiency anemia B12 deficiency Folate deficiency Calcium and Vitamin D deficiency

Not seen with purely restrictive surgeries

Iron deficiency and anemia

Common following RYGB As high as 49 of patients Multifactorial cause

Low gastric acid levels prohibit iron cleavage from food Absorption inhibited because no nutrient exposure to duodenum or

proximal jejunum Decrease in iron-rich food consumption due to intolerance

Treat with oral supplementation of ferrous sulfate or ferrous gluconate

Vitamin B12 deficiency

Up to 70 of patients Lack of hydrochloric acid and pepsin in stomach

Prevents B12 cleavage from food Affects secretion of intrinsic factor thus B12 absorption

Intolerance to meat and milk Oral supplementation usually adequate otherwise IM injections used

Folate Deficiency

40 of gastric bypass patients Complete absorption requires B12 Absorption dependent on HCl and upper 13 stomach Deficiency generally caused by decreased consumption Oral supplementation

Vitamin D and Calcium Deficiency

Vitamin D deficiency is common among obese people Calcium absorption decreased because duodenum is

bypassed Intolerance to dairy foods high in calcium Vitamin D is required for Ca++ absorption Prolonged deficiencies lead to

Bone resorption osteomalacia osteoporosis Treat with calcium citrate supplementation and 2 weekly

doses of Vitamin D

Nutritional Implications of Various Bariatric Surgeries(34)

bull RYGB Malabsorption of Vit B12 Vit B1 (thiamin) Vit D Vit K Folate Iron Calcium

bull LAGB Folic Acid deficiency

bull BPD and BPDDS Vit A D E and K deficiency Protein-Calorie Malnutrition Malabsorption of

Calcium Zinc Selenium Sodium Potassium Chloride Phosphorus Magnesium

Recommended Daily Supplements(4)

Multivitamin with iron (prenatal vitamin will have adeq amount of folic acid)

Calcium (citrate) with vitamin D (1200-1500 mg calcium with 800-1000 IU vitamin D)

Oral vitamin B12 (500-1000 mcg) Iron (65 mgday in elemental form)

Vitamin C (to increase absorption of Iron) Thiamin (10 mgday)

Diet Recommendations(3)

Reduce food volume Chew food very well Slow pace of eating No liquids with meals Encourage fruits and vegetables as diet progresses Include high protein foods (at least 60gday) may need protein

supplements

Diet Progression Gastric Bypass

Stage 1 Clear liquids and protein supplement (1 week)

Stage 2No concentrated sweets low fat puree diet ( 3 weeks)

Stage 3 Regular texture weight reduction diet

Diet Progression Lap - Band

Stage 1 Clear liquids and protein supplement ( 2 weeks)

Stage 2 No concentrated sweets low fat puree diet (2weeks)

Stage 3 Regular texture weight reduction diet

Stage 1

Only clear liquids allowed Avoid sweetened beverages Sip very slowly No straws Avoid caffeinated carbonated and alcoholic beverages STOP drinking if you feel fullness pain or discomfort

Protein supplements

Begin the day after you go home from Hospital

Minimum protein target 70gmsday

May use powder or pre-mixed liquid forms (Whey protein is preferred)

Protein pills may not be used

Vitamin and Mineral Supplements

Gastric bypass patients In addition to eating much less food gastric bypass patients will also

absorb vitamins and minerals differently after surgery They will require daily multivitamin calcium and iron

supplementation for the rest of your life

Vitamin and Mineral Supplements

Lap-Bandreg patients

Require a multivitamin with minerals daily

It may be necessary to take additional vitamins and minerals eg calcium iron folateB1 B12These will be prescribed as needed

Stage 2 dietPUREE

Puree diet

Regular scheduled meals Avoid meal skipping Plan meals in advance Eat Slowly Eat protein foods first Moisten meats Use liquid protein as supplement not as meal replacement

Measure 2 oz portions at each meal eating when full Separate liquids and solids No bread rice or pasta Avoid added sugars and high fat

foods VARIETY

How does the Band work

Surgery Factors Restriction of meal size Decreased appetite

Patient Factors Decreased calorie intake Increased calorie expenditure

LAP-BAND Adjustability

Unfilled Band Filled Band

Adjustments are made in the office

Complications of Gastric Lap-Band

bull Perforation of Stomachbull Slippagebull Gastric Erosion(much less after Pars flaccida technique) bull Dilated Esophagusbull Tubing access port problemsbull Mal positioningbull Abdominal Painbull Heartburnbull Vomitingbull Inability to Adjust the Bandbull Failure to Lose Weightbull Infection of Systembull Fatigue or malfunction

Advantages

No intestinal surgery No staplingcutting of stomach No nutritional risks Adjustable Reversible Safe

Foreign body Frequent follow-up visits Needs more commitment Easy to cheat

Disadvantages

Comparison of Adjustable Gastric Banding and Vertical Banded Gastroplasty

Laparoscopic adjustable gastric banding Reversible Adjustable Simpler to perform laparoscopically Sustained weight loss of gt50 EBW gt5

years following surgery Complications Gastric prolapse band

erosion rarely gastric perforation and access port complications

Vertical banded gastroplasty Irreversible Non adjustable Technically difficult by laparoscopy Weight loss of 25-50 EBW and weight gain

after 2-3 years Complications suture line disruption gastric

leak weight gain

>

>

Originally used as the first-stage operation for a proposed biliopancreatic diversion with duodenal switch in high-risk patients

The sleeve gastrectomy has caught on as a primary obesity treatment as surgeons are reporting weight loss of 55 of excess body weight past 5 years in some patients

The sleeve gastrectomy is also known as the greater curvature gastrectomy vertical or longitudinal gastrectomy or Pylorus preserving lsquogastric tube creationrsquo

Rapid and less traumatic operation Good resolution of co-morbidities and good weight loss

A further second surgical step is then easily feasible if necessary

SLEEVE GASTRECTOMY

SLEEVE GASTRECTOMY

A sleeve gastrectomy involves resection of

approximately 80 of the greater curvature

side of the stomach

Smaller tubular gastric ldquosleeverdquo created

along the lesser curve that is based on the

lesser curvature blood supply

Ideal approximate capacity of the stomach

after the procedure is about 30- 60 ml pouch

1MECHANICAL RESTRICTION by reducing the volume of the stomach and impairing stomach mobility Also called lsquoFood limitingrsquo operation

2HORMONAL MODIFICATION by removing a great part of the Ghrelin (Hunger Hormone) production tissue

(Ghrelin is a 28 amino-acid-peptide secreted by the oxyntic glands of the gastric fungus It is a potent orexigenic (appetite-stimulating) peptide mediated by the activation of its receptors in the hypothalamus or pituitary area)

The gastric fundus contains 10 to 20 times more ghrelin per one gram of tissue than the duodenum In the SG resection of the fundus removes the major portion of ghrelin release therefore appetite decreases

The sleeve gastrectomy (SG) induces weight loss by 2 mechanisms

>

Intragastric balloon involves placing a deflated balloon into the stomach and then filling it to decrease the amount of gastric space

The balloon can be left in the stomach for a maximum of 6 months and results in an average weight loss of 5ndash9 BMI over half a year

Done endoscopically

The intragastric balloon may be used prior to another bariatric surgery as a step-down procedure

INTRA GASTRIC BALLOON

>

>

The EndoBarrier gastrointestinal liner mimics the effects of gastric bypass surgery

Itrsquos designed to work by inserting a flexible

tube-like barrier into the duodenum amp 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

ENDO BARRIER LINER SYSTEM

B MAL- ABSORPTIVE PROCEDURES

Malabsorptive surgeries rearrange andor remove part of digestive system which then limits the amount of calories and nutrients that body can absorb Treatment with a large malabsorptive component results in the most weight loss but tend to have slightly higher complication rates

1JEJUNAL ILEAL BYPASS ndash no longer performed for high complication rates

2ILEAL TRANSPOSITION- New malabsoptive procedure on trial for treatment of DM type 2 and metabolic disorders

C COMBINATION PROCEDURES RESTRICTIVE + MALABSORBTIVE

1LAP GASTRIC BYPASS ndash ROUX-EN- Y ndash more malabsorption than the restrictive

2MINI- GASTRIC BYPASS- mainly restrictive

3DUODENAL SWITCH ndash the sleeve stomach is the restrictive portion ampthe intestinal bypass (duodenal switch) is the malabsorptive component

When surgery combines both restrictive and malabsorptive techniques it is know as a ldquocombinationrdquo procedure Most types of bariatric surgery carry at least a small element of both components but the following surgeries achieve a notable portion of weight loss from eachhellip

1 LAP GASTRIC BYPASS LGB

The Roux-en-Y gastric bypass(known simply as the LRYGBP) is the most commonly performed procedure

It primarily causesweight loss by restricting thefood intake however there ismore amount of mal absorption that occurs with this operation

GASTRIC BYPASS LRYGBP

bullThe stomach is stapled into2 pieces one small and one large The small piece becomes the ldquonewrdquo stomach pouch

bull The larger portion of the stomach stays in place however will lie dormant for the remainder of the patientrsquos life

GASTRIC BYPASS LGB

bull The small intestine (the jejunum) is divided using a surgical staplerApprox 50-70 cm from the DJ Junction

GASTRIC BYPASS LGB

Y- LIMB BP LIMB

bull The end of the Roux limb is then attached to the newly formed stomach pouch which carries food to the distal intestine

bull The Roux loop is completed by forming a jejunostomy

bull The Y limb or BPD limb carries digestive juices from the pancreas gall bladder liver and duodenum to the intestines

bull The food and the digestive juices mix where the Roux limb and Y limb meet much below say 100-150 cm from DJ

Roux limb or alimentary limb

100-150 cm

How Does the Roux-en-Y Work

Surgery factors restriction of meal size ldquodumping syndromerdquo some malabsorption decreased appetite

Patient factors calorie intake calorie expenditure

bull Most commonly performedbull Most reliable operation for long term weight lossbull Long term weight loss averages 60 to 75 percent of EBWbull Malnutrition is unusualbull Substantial improvement amp resolution in many co-morbid

obesity conditions

ADVANTAGES OF RYGBP

1 Not reversible

2 Mortality 05- 1

3 Perioperative complications 5-10

4 Stricture of gastrojejunostomy-10 (long term)

5 Long term risk of protein amp vitamin deficiency and marginal ulceration of GJA

6Long term risk of intestinal obstruction ndash 2

LAPAROSCOPIC GASTRIC BYPASSCOMPLICATIONS

Biliopancreatic Diversion (BPD)

Primarily malabsorptive but restrictive component also

First Terminal ileum is measured to a length of 50 cms marked with suture

The alimentary tract beyond the proximal part of stomach is rearranged to

include only distal 200 cm of ileum including common channel

Common channel-Distal 50 cm of terminal ileum for absorption of fat and

protein

The proximal end of ileum anastomosed to proximal end of stomach after

performing distal hemigastrectomy

Biliopancreatic Diversion with Duodenal Switch

Modification to lessen high incidence of vit b12 deficiency anastomotic stricture at gastrojejunal anastomosis

This procedure involves a sleeve gastrectomy that is then diverted at the duodenum into the ileum at a point measured proximally from the ileocecal valve (usually 250 cm)

The distal duodenum and jejunum the biliopancreatic limb are then anastomosed to the ileum at a point measured proximally from the ileocecal valve (usually 100 cm)

Common channel is 100cm Entire alimentary tract is 250 cm This is the most aggressive bypass procedure commonly offered today Major difference-Sleeve gastrectomy instead of distal hemigastrectomy

bull Most women regained normal menstrual function and most had documented

spontaneous ovulation

bull Significant improvement in hirsutism androgen profiles and about a 50 reduction in

HOMA-IR

bull Follow up for more than 2 years showed that all women resumed normal menstrual

cycles HbA1C decreased from 82 to 51 in lt 3 months

bull 78 saw improvement in metabolic syndrome amp 48 showed improvement in PCOS

2 ROLE OF BARIATRIC SURGERY IN PCOS PATIENTS

bull Decrease menstrual irregularities bull PCOS women have less hyper androgenism

bull Sex hormone binding globulin increases bull LH and FSH levels have been reported to increase

bull Ovulatory function measured by luteal LH and Progesterone secretion improved bull Leptin levels decrease reflecting improved reproductive metabolic status

bull Subclinical hypothyroidism significantly reduced

THE SAFE TIMING OF PREGNANCYoptimal or minimal time gt12 months after bariatric surgery before becoming pregnant in order to allow the rapid weight loss and metabolic changes to subside

4 BARIATRIC SURGERY IN REPRODUCTIVE WOMEN

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)

The foregut hypothesis theory ndash 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

Effect of Bariatric Surgery on Diabetes Mellitus

Combined Gastric Restriction amp Malabsorption

Operative Risks (vs cholecystectomy)

Perioperative Mortality 1-2 vs 02-08 Early Complications 10 vs 29Late Complications 20 vs 1-2

LimitationsWidening of (unbanded) gastrojejunostomyExpansion of gastric pouch 25 with nearly 100 weight regainAdaptation of limb that receives the food

SUMMARY OF ALL TYPES OF SURGERY

bull LRYGBP ndash worlds best procedure 60-70 WL dumping syndrome malnutrition

bull LAGB- low complications varying range of wt loss frequent post-op visits ( 10)

bull DSBPD- more wt loss high complications good for high BMI gt 50 malabsorption +

bull VBG(vertical band gastroplasty) ndash longest available results good wt loss improved co-morbidities right for some ptsrisks too high to justify rewards

bull SG- needs long term research 1st step procedure low risks higher wt loss lesser complications pouch could Stretch over time long staple line could cause problems in future frequency is accelerating because of technical ease 1st stage procedure before bypass

Post-surgical Complications

Anastomosis leaks or staple line leaks Pulmonary Embolism or DVT Cholelithiasis Stomal ulceration Dumping syndrome Constipation

Anastamosis Leaks

Up to 7-10 days after surgery Most common at gastrojejunostomy enteroenterostomy Roux

limb stump staple line Can lead to peritonitis sepsis possible death Presentation

Tachycardia tachypnea Fever Ab painback pain Pelvic pressure or rebound tenderness

Anastamosis Leaks

Order Gastrograffin upper GI series Subclinical cases

Bowel rest Parenteral nutrition IV antibiotic if H pylori

Clinically suspect leak Laparoscopic evaluation and leak repair

Failure to evaluate is the most common cause of preventable major long-term disability or death in bariatric surgical patients

Pulmonary Embolism

Sudden cause of death up to one month after surgery 20-30 mortality rate High risk may have vena cava filter placement prior to surgery Prophylaxis with compression stockings and LMWH Early ambulation imperitive

Pulmonary Embolism

Presentation Profound hypoxia Hypotension Signs of sepsis

Immediate spiral chest CT Abdominal exploration if too large for machine No pathology start anticoagulation Too largehelliphellipNO SURGERY

Cholelithiasis

Up to 36 of patients within 6 months post-op Bile stasis leads to increased sludge and gallstones Prophylactic cholecystectomy prior to surgery if

evidence of existing sludge or stones Prevent post-operative disease with concurrent bariatric

surgery and cholecystectomy Prophylactic use of urosidol

Expensive and unpalatable

Stomal Ulceration

12-15 within 2-4 mos Post-surgery Etiology

Overabundant acid in pouch leads to excessive acid passing through stoma

Pouch tension and staple line breakdown NSAID use

Presentation Dyspepsia vomiting Epigastric or retrosternal pain

Stomal Ulceration

Treatment PPI carafate Antibiotics if H Pylori Avoid NSAIDS alcohol smoking

If no response to treatment Endoscopy Back to surgery for pouch revision or staple line repair

Dumping Syndrome

More than 15 patients Hypotention Tachycardia Lightheadedness syncope Flushing Abdominal cramping and diarrhea Nausea and vomiting

Dumping Syndrome

Occurs with high dose simple sugar ingestion Sugar in small intestine causes osmotic overload and fluid

shift from blood to intestine Increased intestinal volume leads to watery diarrhea Decreased blood volume leads to systemic changes Patient education

Eat slowly Avoid drinking before during and not until 30 minutes after meals

Constipation

Most common complaint Causes

Dehydration and decreased fluid intake post-operatively Increased metabolic water needs Calcium and iron supplement use following surgery

Treat with increased fluids and stool softeners

Nutritional Consequences

Iron deficiency anemia B12 deficiency Folate deficiency Calcium and Vitamin D deficiency

Not seen with purely restrictive surgeries

Iron deficiency and anemia

Common following RYGB As high as 49 of patients Multifactorial cause

Low gastric acid levels prohibit iron cleavage from food Absorption inhibited because no nutrient exposure to duodenum or

proximal jejunum Decrease in iron-rich food consumption due to intolerance

Treat with oral supplementation of ferrous sulfate or ferrous gluconate

Vitamin B12 deficiency

Up to 70 of patients Lack of hydrochloric acid and pepsin in stomach

Prevents B12 cleavage from food Affects secretion of intrinsic factor thus B12 absorption

Intolerance to meat and milk Oral supplementation usually adequate otherwise IM injections used

Folate Deficiency

40 of gastric bypass patients Complete absorption requires B12 Absorption dependent on HCl and upper 13 stomach Deficiency generally caused by decreased consumption Oral supplementation

Vitamin D and Calcium Deficiency

Vitamin D deficiency is common among obese people Calcium absorption decreased because duodenum is

bypassed Intolerance to dairy foods high in calcium Vitamin D is required for Ca++ absorption Prolonged deficiencies lead to

Bone resorption osteomalacia osteoporosis Treat with calcium citrate supplementation and 2 weekly

doses of Vitamin D

Nutritional Implications of Various Bariatric Surgeries(34)

bull RYGB Malabsorption of Vit B12 Vit B1 (thiamin) Vit D Vit K Folate Iron Calcium

bull LAGB Folic Acid deficiency

bull BPD and BPDDS Vit A D E and K deficiency Protein-Calorie Malnutrition Malabsorption of

Calcium Zinc Selenium Sodium Potassium Chloride Phosphorus Magnesium

Recommended Daily Supplements(4)

Multivitamin with iron (prenatal vitamin will have adeq amount of folic acid)

Calcium (citrate) with vitamin D (1200-1500 mg calcium with 800-1000 IU vitamin D)

Oral vitamin B12 (500-1000 mcg) Iron (65 mgday in elemental form)

Vitamin C (to increase absorption of Iron) Thiamin (10 mgday)

Diet Recommendations(3)

Reduce food volume Chew food very well Slow pace of eating No liquids with meals Encourage fruits and vegetables as diet progresses Include high protein foods (at least 60gday) may need protein

supplements

Diet Progression Gastric Bypass

Stage 1 Clear liquids and protein supplement (1 week)

Stage 2No concentrated sweets low fat puree diet ( 3 weeks)

Stage 3 Regular texture weight reduction diet

Diet Progression Lap - Band

Stage 1 Clear liquids and protein supplement ( 2 weeks)

Stage 2 No concentrated sweets low fat puree diet (2weeks)

Stage 3 Regular texture weight reduction diet

Stage 1

Only clear liquids allowed Avoid sweetened beverages Sip very slowly No straws Avoid caffeinated carbonated and alcoholic beverages STOP drinking if you feel fullness pain or discomfort

Protein supplements

Begin the day after you go home from Hospital

Minimum protein target 70gmsday

May use powder or pre-mixed liquid forms (Whey protein is preferred)

Protein pills may not be used

Vitamin and Mineral Supplements

Gastric bypass patients In addition to eating much less food gastric bypass patients will also

absorb vitamins and minerals differently after surgery They will require daily multivitamin calcium and iron

supplementation for the rest of your life

Vitamin and Mineral Supplements

Lap-Bandreg patients

Require a multivitamin with minerals daily

It may be necessary to take additional vitamins and minerals eg calcium iron folateB1 B12These will be prescribed as needed

Stage 2 dietPUREE

Puree diet

Regular scheduled meals Avoid meal skipping Plan meals in advance Eat Slowly Eat protein foods first Moisten meats Use liquid protein as supplement not as meal replacement

Measure 2 oz portions at each meal eating when full Separate liquids and solids No bread rice or pasta Avoid added sugars and high fat

foods VARIETY

LAP-BAND Adjustability

Unfilled Band Filled Band

Adjustments are made in the office

Complications of Gastric Lap-Band

bull Perforation of Stomachbull Slippagebull Gastric Erosion(much less after Pars flaccida technique) bull Dilated Esophagusbull Tubing access port problemsbull Mal positioningbull Abdominal Painbull Heartburnbull Vomitingbull Inability to Adjust the Bandbull Failure to Lose Weightbull Infection of Systembull Fatigue or malfunction

Advantages

No intestinal surgery No staplingcutting of stomach No nutritional risks Adjustable Reversible Safe

Foreign body Frequent follow-up visits Needs more commitment Easy to cheat

Disadvantages

Comparison of Adjustable Gastric Banding and Vertical Banded Gastroplasty

Laparoscopic adjustable gastric banding Reversible Adjustable Simpler to perform laparoscopically Sustained weight loss of gt50 EBW gt5

years following surgery Complications Gastric prolapse band

erosion rarely gastric perforation and access port complications

Vertical banded gastroplasty Irreversible Non adjustable Technically difficult by laparoscopy Weight loss of 25-50 EBW and weight gain

after 2-3 years Complications suture line disruption gastric

leak weight gain

>

>

Originally used as the first-stage operation for a proposed biliopancreatic diversion with duodenal switch in high-risk patients

The sleeve gastrectomy has caught on as a primary obesity treatment as surgeons are reporting weight loss of 55 of excess body weight past 5 years in some patients

The sleeve gastrectomy is also known as the greater curvature gastrectomy vertical or longitudinal gastrectomy or Pylorus preserving lsquogastric tube creationrsquo

Rapid and less traumatic operation Good resolution of co-morbidities and good weight loss

A further second surgical step is then easily feasible if necessary

SLEEVE GASTRECTOMY

SLEEVE GASTRECTOMY

A sleeve gastrectomy involves resection of

approximately 80 of the greater curvature

side of the stomach

Smaller tubular gastric ldquosleeverdquo created

along the lesser curve that is based on the

lesser curvature blood supply

Ideal approximate capacity of the stomach

after the procedure is about 30- 60 ml pouch

1MECHANICAL RESTRICTION by reducing the volume of the stomach and impairing stomach mobility Also called lsquoFood limitingrsquo operation

2HORMONAL MODIFICATION by removing a great part of the Ghrelin (Hunger Hormone) production tissue

(Ghrelin is a 28 amino-acid-peptide secreted by the oxyntic glands of the gastric fungus It is a potent orexigenic (appetite-stimulating) peptide mediated by the activation of its receptors in the hypothalamus or pituitary area)

The gastric fundus contains 10 to 20 times more ghrelin per one gram of tissue than the duodenum In the SG resection of the fundus removes the major portion of ghrelin release therefore appetite decreases

The sleeve gastrectomy (SG) induces weight loss by 2 mechanisms

>

Intragastric balloon involves placing a deflated balloon into the stomach and then filling it to decrease the amount of gastric space

The balloon can be left in the stomach for a maximum of 6 months and results in an average weight loss of 5ndash9 BMI over half a year

Done endoscopically

The intragastric balloon may be used prior to another bariatric surgery as a step-down procedure

INTRA GASTRIC BALLOON

>

>

The EndoBarrier gastrointestinal liner mimics the effects of gastric bypass surgery

Itrsquos designed to work by inserting a flexible

tube-like barrier into the duodenum amp 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

ENDO BARRIER LINER SYSTEM

B MAL- ABSORPTIVE PROCEDURES

Malabsorptive surgeries rearrange andor remove part of digestive system which then limits the amount of calories and nutrients that body can absorb Treatment with a large malabsorptive component results in the most weight loss but tend to have slightly higher complication rates

1JEJUNAL ILEAL BYPASS ndash no longer performed for high complication rates

2ILEAL TRANSPOSITION- New malabsoptive procedure on trial for treatment of DM type 2 and metabolic disorders

C COMBINATION PROCEDURES RESTRICTIVE + MALABSORBTIVE

1LAP GASTRIC BYPASS ndash ROUX-EN- Y ndash more malabsorption than the restrictive

2MINI- GASTRIC BYPASS- mainly restrictive

3DUODENAL SWITCH ndash the sleeve stomach is the restrictive portion ampthe intestinal bypass (duodenal switch) is the malabsorptive component

When surgery combines both restrictive and malabsorptive techniques it is know as a ldquocombinationrdquo procedure Most types of bariatric surgery carry at least a small element of both components but the following surgeries achieve a notable portion of weight loss from eachhellip

1 LAP GASTRIC BYPASS LGB

The Roux-en-Y gastric bypass(known simply as the LRYGBP) is the most commonly performed procedure

It primarily causesweight loss by restricting thefood intake however there ismore amount of mal absorption that occurs with this operation

GASTRIC BYPASS LRYGBP

bullThe stomach is stapled into2 pieces one small and one large The small piece becomes the ldquonewrdquo stomach pouch

bull The larger portion of the stomach stays in place however will lie dormant for the remainder of the patientrsquos life

GASTRIC BYPASS LGB

bull The small intestine (the jejunum) is divided using a surgical staplerApprox 50-70 cm from the DJ Junction

GASTRIC BYPASS LGB

Y- LIMB BP LIMB

bull The end of the Roux limb is then attached to the newly formed stomach pouch which carries food to the distal intestine

bull The Roux loop is completed by forming a jejunostomy

bull The Y limb or BPD limb carries digestive juices from the pancreas gall bladder liver and duodenum to the intestines

bull The food and the digestive juices mix where the Roux limb and Y limb meet much below say 100-150 cm from DJ

Roux limb or alimentary limb

100-150 cm

How Does the Roux-en-Y Work

Surgery factors restriction of meal size ldquodumping syndromerdquo some malabsorption decreased appetite

Patient factors calorie intake calorie expenditure

bull Most commonly performedbull Most reliable operation for long term weight lossbull Long term weight loss averages 60 to 75 percent of EBWbull Malnutrition is unusualbull Substantial improvement amp resolution in many co-morbid

obesity conditions

ADVANTAGES OF RYGBP

1 Not reversible

2 Mortality 05- 1

3 Perioperative complications 5-10

4 Stricture of gastrojejunostomy-10 (long term)

5 Long term risk of protein amp vitamin deficiency and marginal ulceration of GJA

6Long term risk of intestinal obstruction ndash 2

LAPAROSCOPIC GASTRIC BYPASSCOMPLICATIONS

Biliopancreatic Diversion (BPD)

Primarily malabsorptive but restrictive component also

First Terminal ileum is measured to a length of 50 cms marked with suture

The alimentary tract beyond the proximal part of stomach is rearranged to

include only distal 200 cm of ileum including common channel

Common channel-Distal 50 cm of terminal ileum for absorption of fat and

protein

The proximal end of ileum anastomosed to proximal end of stomach after

performing distal hemigastrectomy

Biliopancreatic Diversion with Duodenal Switch

Modification to lessen high incidence of vit b12 deficiency anastomotic stricture at gastrojejunal anastomosis

This procedure involves a sleeve gastrectomy that is then diverted at the duodenum into the ileum at a point measured proximally from the ileocecal valve (usually 250 cm)

The distal duodenum and jejunum the biliopancreatic limb are then anastomosed to the ileum at a point measured proximally from the ileocecal valve (usually 100 cm)

Common channel is 100cm Entire alimentary tract is 250 cm This is the most aggressive bypass procedure commonly offered today Major difference-Sleeve gastrectomy instead of distal hemigastrectomy

bull Most women regained normal menstrual function and most had documented

spontaneous ovulation

bull Significant improvement in hirsutism androgen profiles and about a 50 reduction in

HOMA-IR

bull Follow up for more than 2 years showed that all women resumed normal menstrual

cycles HbA1C decreased from 82 to 51 in lt 3 months

bull 78 saw improvement in metabolic syndrome amp 48 showed improvement in PCOS

2 ROLE OF BARIATRIC SURGERY IN PCOS PATIENTS

bull Decrease menstrual irregularities bull PCOS women have less hyper androgenism

bull Sex hormone binding globulin increases bull LH and FSH levels have been reported to increase

bull Ovulatory function measured by luteal LH and Progesterone secretion improved bull Leptin levels decrease reflecting improved reproductive metabolic status

bull Subclinical hypothyroidism significantly reduced

THE SAFE TIMING OF PREGNANCYoptimal or minimal time gt12 months after bariatric surgery before becoming pregnant in order to allow the rapid weight loss and metabolic changes to subside

4 BARIATRIC SURGERY IN REPRODUCTIVE WOMEN

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)

The foregut hypothesis theory ndash 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

Effect of Bariatric Surgery on Diabetes Mellitus

Combined Gastric Restriction amp Malabsorption

Operative Risks (vs cholecystectomy)

Perioperative Mortality 1-2 vs 02-08 Early Complications 10 vs 29Late Complications 20 vs 1-2

LimitationsWidening of (unbanded) gastrojejunostomyExpansion of gastric pouch 25 with nearly 100 weight regainAdaptation of limb that receives the food

SUMMARY OF ALL TYPES OF SURGERY

bull LRYGBP ndash worlds best procedure 60-70 WL dumping syndrome malnutrition

bull LAGB- low complications varying range of wt loss frequent post-op visits ( 10)

bull DSBPD- more wt loss high complications good for high BMI gt 50 malabsorption +

bull VBG(vertical band gastroplasty) ndash longest available results good wt loss improved co-morbidities right for some ptsrisks too high to justify rewards

bull SG- needs long term research 1st step procedure low risks higher wt loss lesser complications pouch could Stretch over time long staple line could cause problems in future frequency is accelerating because of technical ease 1st stage procedure before bypass

Post-surgical Complications

Anastomosis leaks or staple line leaks Pulmonary Embolism or DVT Cholelithiasis Stomal ulceration Dumping syndrome Constipation

Anastamosis Leaks

Up to 7-10 days after surgery Most common at gastrojejunostomy enteroenterostomy Roux

limb stump staple line Can lead to peritonitis sepsis possible death Presentation

Tachycardia tachypnea Fever Ab painback pain Pelvic pressure or rebound tenderness

Anastamosis Leaks

Order Gastrograffin upper GI series Subclinical cases

Bowel rest Parenteral nutrition IV antibiotic if H pylori

Clinically suspect leak Laparoscopic evaluation and leak repair

Failure to evaluate is the most common cause of preventable major long-term disability or death in bariatric surgical patients

Pulmonary Embolism

Sudden cause of death up to one month after surgery 20-30 mortality rate High risk may have vena cava filter placement prior to surgery Prophylaxis with compression stockings and LMWH Early ambulation imperitive

Pulmonary Embolism

Presentation Profound hypoxia Hypotension Signs of sepsis

Immediate spiral chest CT Abdominal exploration if too large for machine No pathology start anticoagulation Too largehelliphellipNO SURGERY

Cholelithiasis

Up to 36 of patients within 6 months post-op Bile stasis leads to increased sludge and gallstones Prophylactic cholecystectomy prior to surgery if

evidence of existing sludge or stones Prevent post-operative disease with concurrent bariatric

surgery and cholecystectomy Prophylactic use of urosidol

Expensive and unpalatable

Stomal Ulceration

12-15 within 2-4 mos Post-surgery Etiology

Overabundant acid in pouch leads to excessive acid passing through stoma

Pouch tension and staple line breakdown NSAID use

Presentation Dyspepsia vomiting Epigastric or retrosternal pain

Stomal Ulceration

Treatment PPI carafate Antibiotics if H Pylori Avoid NSAIDS alcohol smoking

If no response to treatment Endoscopy Back to surgery for pouch revision or staple line repair

Dumping Syndrome

More than 15 patients Hypotention Tachycardia Lightheadedness syncope Flushing Abdominal cramping and diarrhea Nausea and vomiting

Dumping Syndrome

Occurs with high dose simple sugar ingestion Sugar in small intestine causes osmotic overload and fluid

shift from blood to intestine Increased intestinal volume leads to watery diarrhea Decreased blood volume leads to systemic changes Patient education

Eat slowly Avoid drinking before during and not until 30 minutes after meals

Constipation

Most common complaint Causes

Dehydration and decreased fluid intake post-operatively Increased metabolic water needs Calcium and iron supplement use following surgery

Treat with increased fluids and stool softeners

Nutritional Consequences

Iron deficiency anemia B12 deficiency Folate deficiency Calcium and Vitamin D deficiency

Not seen with purely restrictive surgeries

Iron deficiency and anemia

Common following RYGB As high as 49 of patients Multifactorial cause

Low gastric acid levels prohibit iron cleavage from food Absorption inhibited because no nutrient exposure to duodenum or

proximal jejunum Decrease in iron-rich food consumption due to intolerance

Treat with oral supplementation of ferrous sulfate or ferrous gluconate

Vitamin B12 deficiency

Up to 70 of patients Lack of hydrochloric acid and pepsin in stomach

Prevents B12 cleavage from food Affects secretion of intrinsic factor thus B12 absorption

Intolerance to meat and milk Oral supplementation usually adequate otherwise IM injections used

Folate Deficiency

40 of gastric bypass patients Complete absorption requires B12 Absorption dependent on HCl and upper 13 stomach Deficiency generally caused by decreased consumption Oral supplementation

Vitamin D and Calcium Deficiency

Vitamin D deficiency is common among obese people Calcium absorption decreased because duodenum is

bypassed Intolerance to dairy foods high in calcium Vitamin D is required for Ca++ absorption Prolonged deficiencies lead to

Bone resorption osteomalacia osteoporosis Treat with calcium citrate supplementation and 2 weekly

doses of Vitamin D

Nutritional Implications of Various Bariatric Surgeries(34)

bull RYGB Malabsorption of Vit B12 Vit B1 (thiamin) Vit D Vit K Folate Iron Calcium

bull LAGB Folic Acid deficiency

bull BPD and BPDDS Vit A D E and K deficiency Protein-Calorie Malnutrition Malabsorption of

Calcium Zinc Selenium Sodium Potassium Chloride Phosphorus Magnesium

Recommended Daily Supplements(4)

Multivitamin with iron (prenatal vitamin will have adeq amount of folic acid)

Calcium (citrate) with vitamin D (1200-1500 mg calcium with 800-1000 IU vitamin D)

Oral vitamin B12 (500-1000 mcg) Iron (65 mgday in elemental form)

Vitamin C (to increase absorption of Iron) Thiamin (10 mgday)

Diet Recommendations(3)

Reduce food volume Chew food very well Slow pace of eating No liquids with meals Encourage fruits and vegetables as diet progresses Include high protein foods (at least 60gday) may need protein

supplements

Diet Progression Gastric Bypass

Stage 1 Clear liquids and protein supplement (1 week)

Stage 2No concentrated sweets low fat puree diet ( 3 weeks)

Stage 3 Regular texture weight reduction diet

Diet Progression Lap - Band

Stage 1 Clear liquids and protein supplement ( 2 weeks)

Stage 2 No concentrated sweets low fat puree diet (2weeks)

Stage 3 Regular texture weight reduction diet

Stage 1

Only clear liquids allowed Avoid sweetened beverages Sip very slowly No straws Avoid caffeinated carbonated and alcoholic beverages STOP drinking if you feel fullness pain or discomfort

Protein supplements

Begin the day after you go home from Hospital

Minimum protein target 70gmsday

May use powder or pre-mixed liquid forms (Whey protein is preferred)

Protein pills may not be used

Vitamin and Mineral Supplements

Gastric bypass patients In addition to eating much less food gastric bypass patients will also

absorb vitamins and minerals differently after surgery They will require daily multivitamin calcium and iron

supplementation for the rest of your life

Vitamin and Mineral Supplements

Lap-Bandreg patients

Require a multivitamin with minerals daily

It may be necessary to take additional vitamins and minerals eg calcium iron folateB1 B12These will be prescribed as needed

Stage 2 dietPUREE

Puree diet

Regular scheduled meals Avoid meal skipping Plan meals in advance Eat Slowly Eat protein foods first Moisten meats Use liquid protein as supplement not as meal replacement

Measure 2 oz portions at each meal eating when full Separate liquids and solids No bread rice or pasta Avoid added sugars and high fat

foods VARIETY

Adjustments are made in the office

Complications of Gastric Lap-Band

bull Perforation of Stomachbull Slippagebull Gastric Erosion(much less after Pars flaccida technique) bull Dilated Esophagusbull Tubing access port problemsbull Mal positioningbull Abdominal Painbull Heartburnbull Vomitingbull Inability to Adjust the Bandbull Failure to Lose Weightbull Infection of Systembull Fatigue or malfunction

Advantages

No intestinal surgery No staplingcutting of stomach No nutritional risks Adjustable Reversible Safe

Foreign body Frequent follow-up visits Needs more commitment Easy to cheat

Disadvantages

Comparison of Adjustable Gastric Banding and Vertical Banded Gastroplasty

Laparoscopic adjustable gastric banding Reversible Adjustable Simpler to perform laparoscopically Sustained weight loss of gt50 EBW gt5

years following surgery Complications Gastric prolapse band

erosion rarely gastric perforation and access port complications

Vertical banded gastroplasty Irreversible Non adjustable Technically difficult by laparoscopy Weight loss of 25-50 EBW and weight gain

after 2-3 years Complications suture line disruption gastric

leak weight gain

>

>

Originally used as the first-stage operation for a proposed biliopancreatic diversion with duodenal switch in high-risk patients

The sleeve gastrectomy has caught on as a primary obesity treatment as surgeons are reporting weight loss of 55 of excess body weight past 5 years in some patients

The sleeve gastrectomy is also known as the greater curvature gastrectomy vertical or longitudinal gastrectomy or Pylorus preserving lsquogastric tube creationrsquo

Rapid and less traumatic operation Good resolution of co-morbidities and good weight loss

A further second surgical step is then easily feasible if necessary

SLEEVE GASTRECTOMY

SLEEVE GASTRECTOMY

A sleeve gastrectomy involves resection of

approximately 80 of the greater curvature

side of the stomach

Smaller tubular gastric ldquosleeverdquo created

along the lesser curve that is based on the

lesser curvature blood supply

Ideal approximate capacity of the stomach

after the procedure is about 30- 60 ml pouch

1MECHANICAL RESTRICTION by reducing the volume of the stomach and impairing stomach mobility Also called lsquoFood limitingrsquo operation

2HORMONAL MODIFICATION by removing a great part of the Ghrelin (Hunger Hormone) production tissue

(Ghrelin is a 28 amino-acid-peptide secreted by the oxyntic glands of the gastric fungus It is a potent orexigenic (appetite-stimulating) peptide mediated by the activation of its receptors in the hypothalamus or pituitary area)

The gastric fundus contains 10 to 20 times more ghrelin per one gram of tissue than the duodenum In the SG resection of the fundus removes the major portion of ghrelin release therefore appetite decreases

The sleeve gastrectomy (SG) induces weight loss by 2 mechanisms

>

Intragastric balloon involves placing a deflated balloon into the stomach and then filling it to decrease the amount of gastric space

The balloon can be left in the stomach for a maximum of 6 months and results in an average weight loss of 5ndash9 BMI over half a year

Done endoscopically

The intragastric balloon may be used prior to another bariatric surgery as a step-down procedure

INTRA GASTRIC BALLOON

>

>

The EndoBarrier gastrointestinal liner mimics the effects of gastric bypass surgery

Itrsquos designed to work by inserting a flexible

tube-like barrier into the duodenum amp 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

ENDO BARRIER LINER SYSTEM

B MAL- ABSORPTIVE PROCEDURES

Malabsorptive surgeries rearrange andor remove part of digestive system which then limits the amount of calories and nutrients that body can absorb Treatment with a large malabsorptive component results in the most weight loss but tend to have slightly higher complication rates

1JEJUNAL ILEAL BYPASS ndash no longer performed for high complication rates

2ILEAL TRANSPOSITION- New malabsoptive procedure on trial for treatment of DM type 2 and metabolic disorders

C COMBINATION PROCEDURES RESTRICTIVE + MALABSORBTIVE

1LAP GASTRIC BYPASS ndash ROUX-EN- Y ndash more malabsorption than the restrictive

2MINI- GASTRIC BYPASS- mainly restrictive

3DUODENAL SWITCH ndash the sleeve stomach is the restrictive portion ampthe intestinal bypass (duodenal switch) is the malabsorptive component

When surgery combines both restrictive and malabsorptive techniques it is know as a ldquocombinationrdquo procedure Most types of bariatric surgery carry at least a small element of both components but the following surgeries achieve a notable portion of weight loss from eachhellip

1 LAP GASTRIC BYPASS LGB

The Roux-en-Y gastric bypass(known simply as the LRYGBP) is the most commonly performed procedure

It primarily causesweight loss by restricting thefood intake however there ismore amount of mal absorption that occurs with this operation

GASTRIC BYPASS LRYGBP

bullThe stomach is stapled into2 pieces one small and one large The small piece becomes the ldquonewrdquo stomach pouch

bull The larger portion of the stomach stays in place however will lie dormant for the remainder of the patientrsquos life

GASTRIC BYPASS LGB

bull The small intestine (the jejunum) is divided using a surgical staplerApprox 50-70 cm from the DJ Junction

GASTRIC BYPASS LGB

Y- LIMB BP LIMB

bull The end of the Roux limb is then attached to the newly formed stomach pouch which carries food to the distal intestine

bull The Roux loop is completed by forming a jejunostomy

bull The Y limb or BPD limb carries digestive juices from the pancreas gall bladder liver and duodenum to the intestines

bull The food and the digestive juices mix where the Roux limb and Y limb meet much below say 100-150 cm from DJ

Roux limb or alimentary limb

100-150 cm

How Does the Roux-en-Y Work

Surgery factors restriction of meal size ldquodumping syndromerdquo some malabsorption decreased appetite

Patient factors calorie intake calorie expenditure

bull Most commonly performedbull Most reliable operation for long term weight lossbull Long term weight loss averages 60 to 75 percent of EBWbull Malnutrition is unusualbull Substantial improvement amp resolution in many co-morbid

obesity conditions

ADVANTAGES OF RYGBP

1 Not reversible

2 Mortality 05- 1

3 Perioperative complications 5-10

4 Stricture of gastrojejunostomy-10 (long term)

5 Long term risk of protein amp vitamin deficiency and marginal ulceration of GJA

6Long term risk of intestinal obstruction ndash 2

LAPAROSCOPIC GASTRIC BYPASSCOMPLICATIONS

Biliopancreatic Diversion (BPD)

Primarily malabsorptive but restrictive component also

First Terminal ileum is measured to a length of 50 cms marked with suture

The alimentary tract beyond the proximal part of stomach is rearranged to

include only distal 200 cm of ileum including common channel

Common channel-Distal 50 cm of terminal ileum for absorption of fat and

protein

The proximal end of ileum anastomosed to proximal end of stomach after

performing distal hemigastrectomy

Biliopancreatic Diversion with Duodenal Switch

Modification to lessen high incidence of vit b12 deficiency anastomotic stricture at gastrojejunal anastomosis

This procedure involves a sleeve gastrectomy that is then diverted at the duodenum into the ileum at a point measured proximally from the ileocecal valve (usually 250 cm)

The distal duodenum and jejunum the biliopancreatic limb are then anastomosed to the ileum at a point measured proximally from the ileocecal valve (usually 100 cm)

Common channel is 100cm Entire alimentary tract is 250 cm This is the most aggressive bypass procedure commonly offered today Major difference-Sleeve gastrectomy instead of distal hemigastrectomy

bull Most women regained normal menstrual function and most had documented

spontaneous ovulation

bull Significant improvement in hirsutism androgen profiles and about a 50 reduction in

HOMA-IR

bull Follow up for more than 2 years showed that all women resumed normal menstrual

cycles HbA1C decreased from 82 to 51 in lt 3 months

bull 78 saw improvement in metabolic syndrome amp 48 showed improvement in PCOS

2 ROLE OF BARIATRIC SURGERY IN PCOS PATIENTS

bull Decrease menstrual irregularities bull PCOS women have less hyper androgenism

bull Sex hormone binding globulin increases bull LH and FSH levels have been reported to increase

bull Ovulatory function measured by luteal LH and Progesterone secretion improved bull Leptin levels decrease reflecting improved reproductive metabolic status

bull Subclinical hypothyroidism significantly reduced

THE SAFE TIMING OF PREGNANCYoptimal or minimal time gt12 months after bariatric surgery before becoming pregnant in order to allow the rapid weight loss and metabolic changes to subside

4 BARIATRIC SURGERY IN REPRODUCTIVE WOMEN

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)

The foregut hypothesis theory ndash 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

Effect of Bariatric Surgery on Diabetes Mellitus

Combined Gastric Restriction amp Malabsorption

Operative Risks (vs cholecystectomy)

Perioperative Mortality 1-2 vs 02-08 Early Complications 10 vs 29Late Complications 20 vs 1-2

LimitationsWidening of (unbanded) gastrojejunostomyExpansion of gastric pouch 25 with nearly 100 weight regainAdaptation of limb that receives the food

SUMMARY OF ALL TYPES OF SURGERY

bull LRYGBP ndash worlds best procedure 60-70 WL dumping syndrome malnutrition

bull LAGB- low complications varying range of wt loss frequent post-op visits ( 10)

bull DSBPD- more wt loss high complications good for high BMI gt 50 malabsorption +

bull VBG(vertical band gastroplasty) ndash longest available results good wt loss improved co-morbidities right for some ptsrisks too high to justify rewards

bull SG- needs long term research 1st step procedure low risks higher wt loss lesser complications pouch could Stretch over time long staple line could cause problems in future frequency is accelerating because of technical ease 1st stage procedure before bypass

Post-surgical Complications

Anastomosis leaks or staple line leaks Pulmonary Embolism or DVT Cholelithiasis Stomal ulceration Dumping syndrome Constipation

Anastamosis Leaks

Up to 7-10 days after surgery Most common at gastrojejunostomy enteroenterostomy Roux

limb stump staple line Can lead to peritonitis sepsis possible death Presentation

Tachycardia tachypnea Fever Ab painback pain Pelvic pressure or rebound tenderness

Anastamosis Leaks

Order Gastrograffin upper GI series Subclinical cases

Bowel rest Parenteral nutrition IV antibiotic if H pylori

Clinically suspect leak Laparoscopic evaluation and leak repair

Failure to evaluate is the most common cause of preventable major long-term disability or death in bariatric surgical patients

Pulmonary Embolism

Sudden cause of death up to one month after surgery 20-30 mortality rate High risk may have vena cava filter placement prior to surgery Prophylaxis with compression stockings and LMWH Early ambulation imperitive

Pulmonary Embolism

Presentation Profound hypoxia Hypotension Signs of sepsis

Immediate spiral chest CT Abdominal exploration if too large for machine No pathology start anticoagulation Too largehelliphellipNO SURGERY

Cholelithiasis

Up to 36 of patients within 6 months post-op Bile stasis leads to increased sludge and gallstones Prophylactic cholecystectomy prior to surgery if

evidence of existing sludge or stones Prevent post-operative disease with concurrent bariatric

surgery and cholecystectomy Prophylactic use of urosidol

Expensive and unpalatable

Stomal Ulceration

12-15 within 2-4 mos Post-surgery Etiology

Overabundant acid in pouch leads to excessive acid passing through stoma

Pouch tension and staple line breakdown NSAID use

Presentation Dyspepsia vomiting Epigastric or retrosternal pain

Stomal Ulceration

Treatment PPI carafate Antibiotics if H Pylori Avoid NSAIDS alcohol smoking

If no response to treatment Endoscopy Back to surgery for pouch revision or staple line repair

Dumping Syndrome

More than 15 patients Hypotention Tachycardia Lightheadedness syncope Flushing Abdominal cramping and diarrhea Nausea and vomiting

Dumping Syndrome

Occurs with high dose simple sugar ingestion Sugar in small intestine causes osmotic overload and fluid

shift from blood to intestine Increased intestinal volume leads to watery diarrhea Decreased blood volume leads to systemic changes Patient education

Eat slowly Avoid drinking before during and not until 30 minutes after meals

Constipation

Most common complaint Causes

Dehydration and decreased fluid intake post-operatively Increased metabolic water needs Calcium and iron supplement use following surgery

Treat with increased fluids and stool softeners

Nutritional Consequences

Iron deficiency anemia B12 deficiency Folate deficiency Calcium and Vitamin D deficiency

Not seen with purely restrictive surgeries

Iron deficiency and anemia

Common following RYGB As high as 49 of patients Multifactorial cause

Low gastric acid levels prohibit iron cleavage from food Absorption inhibited because no nutrient exposure to duodenum or

proximal jejunum Decrease in iron-rich food consumption due to intolerance

Treat with oral supplementation of ferrous sulfate or ferrous gluconate

Vitamin B12 deficiency

Up to 70 of patients Lack of hydrochloric acid and pepsin in stomach

Prevents B12 cleavage from food Affects secretion of intrinsic factor thus B12 absorption

Intolerance to meat and milk Oral supplementation usually adequate otherwise IM injections used

Folate Deficiency

40 of gastric bypass patients Complete absorption requires B12 Absorption dependent on HCl and upper 13 stomach Deficiency generally caused by decreased consumption Oral supplementation

Vitamin D and Calcium Deficiency

Vitamin D deficiency is common among obese people Calcium absorption decreased because duodenum is

bypassed Intolerance to dairy foods high in calcium Vitamin D is required for Ca++ absorption Prolonged deficiencies lead to

Bone resorption osteomalacia osteoporosis Treat with calcium citrate supplementation and 2 weekly

doses of Vitamin D

Nutritional Implications of Various Bariatric Surgeries(34)

bull RYGB Malabsorption of Vit B12 Vit B1 (thiamin) Vit D Vit K Folate Iron Calcium

bull LAGB Folic Acid deficiency

bull BPD and BPDDS Vit A D E and K deficiency Protein-Calorie Malnutrition Malabsorption of

Calcium Zinc Selenium Sodium Potassium Chloride Phosphorus Magnesium

Recommended Daily Supplements(4)

Multivitamin with iron (prenatal vitamin will have adeq amount of folic acid)

Calcium (citrate) with vitamin D (1200-1500 mg calcium with 800-1000 IU vitamin D)

Oral vitamin B12 (500-1000 mcg) Iron (65 mgday in elemental form)

Vitamin C (to increase absorption of Iron) Thiamin (10 mgday)

Diet Recommendations(3)

Reduce food volume Chew food very well Slow pace of eating No liquids with meals Encourage fruits and vegetables as diet progresses Include high protein foods (at least 60gday) may need protein

supplements

Diet Progression Gastric Bypass

Stage 1 Clear liquids and protein supplement (1 week)

Stage 2No concentrated sweets low fat puree diet ( 3 weeks)

Stage 3 Regular texture weight reduction diet

Diet Progression Lap - Band

Stage 1 Clear liquids and protein supplement ( 2 weeks)

Stage 2 No concentrated sweets low fat puree diet (2weeks)

Stage 3 Regular texture weight reduction diet

Stage 1

Only clear liquids allowed Avoid sweetened beverages Sip very slowly No straws Avoid caffeinated carbonated and alcoholic beverages STOP drinking if you feel fullness pain or discomfort

Protein supplements

Begin the day after you go home from Hospital

Minimum protein target 70gmsday

May use powder or pre-mixed liquid forms (Whey protein is preferred)

Protein pills may not be used

Vitamin and Mineral Supplements

Gastric bypass patients In addition to eating much less food gastric bypass patients will also

absorb vitamins and minerals differently after surgery They will require daily multivitamin calcium and iron

supplementation for the rest of your life

Vitamin and Mineral Supplements

Lap-Bandreg patients

Require a multivitamin with minerals daily

It may be necessary to take additional vitamins and minerals eg calcium iron folateB1 B12These will be prescribed as needed

Stage 2 dietPUREE

Puree diet

Regular scheduled meals Avoid meal skipping Plan meals in advance Eat Slowly Eat protein foods first Moisten meats Use liquid protein as supplement not as meal replacement

Measure 2 oz portions at each meal eating when full Separate liquids and solids No bread rice or pasta Avoid added sugars and high fat

foods VARIETY

Complications of Gastric Lap-Band

bull Perforation of Stomachbull Slippagebull Gastric Erosion(much less after Pars flaccida technique) bull Dilated Esophagusbull Tubing access port problemsbull Mal positioningbull Abdominal Painbull Heartburnbull Vomitingbull Inability to Adjust the Bandbull Failure to Lose Weightbull Infection of Systembull Fatigue or malfunction

Advantages

No intestinal surgery No staplingcutting of stomach No nutritional risks Adjustable Reversible Safe

Foreign body Frequent follow-up visits Needs more commitment Easy to cheat

Disadvantages

Comparison of Adjustable Gastric Banding and Vertical Banded Gastroplasty

Laparoscopic adjustable gastric banding Reversible Adjustable Simpler to perform laparoscopically Sustained weight loss of gt50 EBW gt5

years following surgery Complications Gastric prolapse band

erosion rarely gastric perforation and access port complications

Vertical banded gastroplasty Irreversible Non adjustable Technically difficult by laparoscopy Weight loss of 25-50 EBW and weight gain

after 2-3 years Complications suture line disruption gastric

leak weight gain

>

>

Originally used as the first-stage operation for a proposed biliopancreatic diversion with duodenal switch in high-risk patients

The sleeve gastrectomy has caught on as a primary obesity treatment as surgeons are reporting weight loss of 55 of excess body weight past 5 years in some patients

The sleeve gastrectomy is also known as the greater curvature gastrectomy vertical or longitudinal gastrectomy or Pylorus preserving lsquogastric tube creationrsquo

Rapid and less traumatic operation Good resolution of co-morbidities and good weight loss

A further second surgical step is then easily feasible if necessary

SLEEVE GASTRECTOMY

SLEEVE GASTRECTOMY

A sleeve gastrectomy involves resection of

approximately 80 of the greater curvature

side of the stomach

Smaller tubular gastric ldquosleeverdquo created

along the lesser curve that is based on the

lesser curvature blood supply

Ideal approximate capacity of the stomach

after the procedure is about 30- 60 ml pouch

1MECHANICAL RESTRICTION by reducing the volume of the stomach and impairing stomach mobility Also called lsquoFood limitingrsquo operation

2HORMONAL MODIFICATION by removing a great part of the Ghrelin (Hunger Hormone) production tissue

(Ghrelin is a 28 amino-acid-peptide secreted by the oxyntic glands of the gastric fungus It is a potent orexigenic (appetite-stimulating) peptide mediated by the activation of its receptors in the hypothalamus or pituitary area)

The gastric fundus contains 10 to 20 times more ghrelin per one gram of tissue than the duodenum In the SG resection of the fundus removes the major portion of ghrelin release therefore appetite decreases

The sleeve gastrectomy (SG) induces weight loss by 2 mechanisms

>

Intragastric balloon involves placing a deflated balloon into the stomach and then filling it to decrease the amount of gastric space

The balloon can be left in the stomach for a maximum of 6 months and results in an average weight loss of 5ndash9 BMI over half a year

Done endoscopically

The intragastric balloon may be used prior to another bariatric surgery as a step-down procedure

INTRA GASTRIC BALLOON

>

>

The EndoBarrier gastrointestinal liner mimics the effects of gastric bypass surgery

Itrsquos designed to work by inserting a flexible

tube-like barrier into the duodenum amp 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

ENDO BARRIER LINER SYSTEM

B MAL- ABSORPTIVE PROCEDURES

Malabsorptive surgeries rearrange andor remove part of digestive system which then limits the amount of calories and nutrients that body can absorb Treatment with a large malabsorptive component results in the most weight loss but tend to have slightly higher complication rates

1JEJUNAL ILEAL BYPASS ndash no longer performed for high complication rates

2ILEAL TRANSPOSITION- New malabsoptive procedure on trial for treatment of DM type 2 and metabolic disorders

C COMBINATION PROCEDURES RESTRICTIVE + MALABSORBTIVE

1LAP GASTRIC BYPASS ndash ROUX-EN- Y ndash more malabsorption than the restrictive

2MINI- GASTRIC BYPASS- mainly restrictive

3DUODENAL SWITCH ndash the sleeve stomach is the restrictive portion ampthe intestinal bypass (duodenal switch) is the malabsorptive component

When surgery combines both restrictive and malabsorptive techniques it is know as a ldquocombinationrdquo procedure Most types of bariatric surgery carry at least a small element of both components but the following surgeries achieve a notable portion of weight loss from eachhellip

1 LAP GASTRIC BYPASS LGB

The Roux-en-Y gastric bypass(known simply as the LRYGBP) is the most commonly performed procedure

It primarily causesweight loss by restricting thefood intake however there ismore amount of mal absorption that occurs with this operation

GASTRIC BYPASS LRYGBP

bullThe stomach is stapled into2 pieces one small and one large The small piece becomes the ldquonewrdquo stomach pouch

bull The larger portion of the stomach stays in place however will lie dormant for the remainder of the patientrsquos life

GASTRIC BYPASS LGB

bull The small intestine (the jejunum) is divided using a surgical staplerApprox 50-70 cm from the DJ Junction

GASTRIC BYPASS LGB

Y- LIMB BP LIMB

bull The end of the Roux limb is then attached to the newly formed stomach pouch which carries food to the distal intestine

bull The Roux loop is completed by forming a jejunostomy

bull The Y limb or BPD limb carries digestive juices from the pancreas gall bladder liver and duodenum to the intestines

bull The food and the digestive juices mix where the Roux limb and Y limb meet much below say 100-150 cm from DJ

Roux limb or alimentary limb

100-150 cm

How Does the Roux-en-Y Work

Surgery factors restriction of meal size ldquodumping syndromerdquo some malabsorption decreased appetite

Patient factors calorie intake calorie expenditure

bull Most commonly performedbull Most reliable operation for long term weight lossbull Long term weight loss averages 60 to 75 percent of EBWbull Malnutrition is unusualbull Substantial improvement amp resolution in many co-morbid

obesity conditions

ADVANTAGES OF RYGBP

1 Not reversible

2 Mortality 05- 1

3 Perioperative complications 5-10

4 Stricture of gastrojejunostomy-10 (long term)

5 Long term risk of protein amp vitamin deficiency and marginal ulceration of GJA

6Long term risk of intestinal obstruction ndash 2

LAPAROSCOPIC GASTRIC BYPASSCOMPLICATIONS

Biliopancreatic Diversion (BPD)

Primarily malabsorptive but restrictive component also

First Terminal ileum is measured to a length of 50 cms marked with suture

The alimentary tract beyond the proximal part of stomach is rearranged to

include only distal 200 cm of ileum including common channel

Common channel-Distal 50 cm of terminal ileum for absorption of fat and

protein

The proximal end of ileum anastomosed to proximal end of stomach after

performing distal hemigastrectomy

Biliopancreatic Diversion with Duodenal Switch

Modification to lessen high incidence of vit b12 deficiency anastomotic stricture at gastrojejunal anastomosis

This procedure involves a sleeve gastrectomy that is then diverted at the duodenum into the ileum at a point measured proximally from the ileocecal valve (usually 250 cm)

The distal duodenum and jejunum the biliopancreatic limb are then anastomosed to the ileum at a point measured proximally from the ileocecal valve (usually 100 cm)

Common channel is 100cm Entire alimentary tract is 250 cm This is the most aggressive bypass procedure commonly offered today Major difference-Sleeve gastrectomy instead of distal hemigastrectomy

bull Most women regained normal menstrual function and most had documented

spontaneous ovulation

bull Significant improvement in hirsutism androgen profiles and about a 50 reduction in

HOMA-IR

bull Follow up for more than 2 years showed that all women resumed normal menstrual

cycles HbA1C decreased from 82 to 51 in lt 3 months

bull 78 saw improvement in metabolic syndrome amp 48 showed improvement in PCOS

2 ROLE OF BARIATRIC SURGERY IN PCOS PATIENTS

bull Decrease menstrual irregularities bull PCOS women have less hyper androgenism

bull Sex hormone binding globulin increases bull LH and FSH levels have been reported to increase

bull Ovulatory function measured by luteal LH and Progesterone secretion improved bull Leptin levels decrease reflecting improved reproductive metabolic status

bull Subclinical hypothyroidism significantly reduced

THE SAFE TIMING OF PREGNANCYoptimal or minimal time gt12 months after bariatric surgery before becoming pregnant in order to allow the rapid weight loss and metabolic changes to subside

4 BARIATRIC SURGERY IN REPRODUCTIVE WOMEN

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)

The foregut hypothesis theory ndash 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

Effect of Bariatric Surgery on Diabetes Mellitus

Combined Gastric Restriction amp Malabsorption

Operative Risks (vs cholecystectomy)

Perioperative Mortality 1-2 vs 02-08 Early Complications 10 vs 29Late Complications 20 vs 1-2

LimitationsWidening of (unbanded) gastrojejunostomyExpansion of gastric pouch 25 with nearly 100 weight regainAdaptation of limb that receives the food

SUMMARY OF ALL TYPES OF SURGERY

bull LRYGBP ndash worlds best procedure 60-70 WL dumping syndrome malnutrition

bull LAGB- low complications varying range of wt loss frequent post-op visits ( 10)

bull DSBPD- more wt loss high complications good for high BMI gt 50 malabsorption +

bull VBG(vertical band gastroplasty) ndash longest available results good wt loss improved co-morbidities right for some ptsrisks too high to justify rewards

bull SG- needs long term research 1st step procedure low risks higher wt loss lesser complications pouch could Stretch over time long staple line could cause problems in future frequency is accelerating because of technical ease 1st stage procedure before bypass

Post-surgical Complications

Anastomosis leaks or staple line leaks Pulmonary Embolism or DVT Cholelithiasis Stomal ulceration Dumping syndrome Constipation

Anastamosis Leaks

Up to 7-10 days after surgery Most common at gastrojejunostomy enteroenterostomy Roux

limb stump staple line Can lead to peritonitis sepsis possible death Presentation

Tachycardia tachypnea Fever Ab painback pain Pelvic pressure or rebound tenderness

Anastamosis Leaks

Order Gastrograffin upper GI series Subclinical cases

Bowel rest Parenteral nutrition IV antibiotic if H pylori

Clinically suspect leak Laparoscopic evaluation and leak repair

Failure to evaluate is the most common cause of preventable major long-term disability or death in bariatric surgical patients

Pulmonary Embolism

Sudden cause of death up to one month after surgery 20-30 mortality rate High risk may have vena cava filter placement prior to surgery Prophylaxis with compression stockings and LMWH Early ambulation imperitive

Pulmonary Embolism

Presentation Profound hypoxia Hypotension Signs of sepsis

Immediate spiral chest CT Abdominal exploration if too large for machine No pathology start anticoagulation Too largehelliphellipNO SURGERY

Cholelithiasis

Up to 36 of patients within 6 months post-op Bile stasis leads to increased sludge and gallstones Prophylactic cholecystectomy prior to surgery if

evidence of existing sludge or stones Prevent post-operative disease with concurrent bariatric

surgery and cholecystectomy Prophylactic use of urosidol

Expensive and unpalatable

Stomal Ulceration

12-15 within 2-4 mos Post-surgery Etiology

Overabundant acid in pouch leads to excessive acid passing through stoma

Pouch tension and staple line breakdown NSAID use

Presentation Dyspepsia vomiting Epigastric or retrosternal pain

Stomal Ulceration

Treatment PPI carafate Antibiotics if H Pylori Avoid NSAIDS alcohol smoking

If no response to treatment Endoscopy Back to surgery for pouch revision or staple line repair

Dumping Syndrome

More than 15 patients Hypotention Tachycardia Lightheadedness syncope Flushing Abdominal cramping and diarrhea Nausea and vomiting

Dumping Syndrome

Occurs with high dose simple sugar ingestion Sugar in small intestine causes osmotic overload and fluid

shift from blood to intestine Increased intestinal volume leads to watery diarrhea Decreased blood volume leads to systemic changes Patient education

Eat slowly Avoid drinking before during and not until 30 minutes after meals

Constipation

Most common complaint Causes

Dehydration and decreased fluid intake post-operatively Increased metabolic water needs Calcium and iron supplement use following surgery

Treat with increased fluids and stool softeners

Nutritional Consequences

Iron deficiency anemia B12 deficiency Folate deficiency Calcium and Vitamin D deficiency

Not seen with purely restrictive surgeries

Iron deficiency and anemia

Common following RYGB As high as 49 of patients Multifactorial cause

Low gastric acid levels prohibit iron cleavage from food Absorption inhibited because no nutrient exposure to duodenum or

proximal jejunum Decrease in iron-rich food consumption due to intolerance

Treat with oral supplementation of ferrous sulfate or ferrous gluconate

Vitamin B12 deficiency

Up to 70 of patients Lack of hydrochloric acid and pepsin in stomach

Prevents B12 cleavage from food Affects secretion of intrinsic factor thus B12 absorption

Intolerance to meat and milk Oral supplementation usually adequate otherwise IM injections used

Folate Deficiency

40 of gastric bypass patients Complete absorption requires B12 Absorption dependent on HCl and upper 13 stomach Deficiency generally caused by decreased consumption Oral supplementation

Vitamin D and Calcium Deficiency

Vitamin D deficiency is common among obese people Calcium absorption decreased because duodenum is

bypassed Intolerance to dairy foods high in calcium Vitamin D is required for Ca++ absorption Prolonged deficiencies lead to

Bone resorption osteomalacia osteoporosis Treat with calcium citrate supplementation and 2 weekly

doses of Vitamin D

Nutritional Implications of Various Bariatric Surgeries(34)

bull RYGB Malabsorption of Vit B12 Vit B1 (thiamin) Vit D Vit K Folate Iron Calcium

bull LAGB Folic Acid deficiency

bull BPD and BPDDS Vit A D E and K deficiency Protein-Calorie Malnutrition Malabsorption of

Calcium Zinc Selenium Sodium Potassium Chloride Phosphorus Magnesium

Recommended Daily Supplements(4)

Multivitamin with iron (prenatal vitamin will have adeq amount of folic acid)

Calcium (citrate) with vitamin D (1200-1500 mg calcium with 800-1000 IU vitamin D)

Oral vitamin B12 (500-1000 mcg) Iron (65 mgday in elemental form)

Vitamin C (to increase absorption of Iron) Thiamin (10 mgday)

Diet Recommendations(3)

Reduce food volume Chew food very well Slow pace of eating No liquids with meals Encourage fruits and vegetables as diet progresses Include high protein foods (at least 60gday) may need protein

supplements

Diet Progression Gastric Bypass

Stage 1 Clear liquids and protein supplement (1 week)

Stage 2No concentrated sweets low fat puree diet ( 3 weeks)

Stage 3 Regular texture weight reduction diet

Diet Progression Lap - Band

Stage 1 Clear liquids and protein supplement ( 2 weeks)

Stage 2 No concentrated sweets low fat puree diet (2weeks)

Stage 3 Regular texture weight reduction diet

Stage 1

Only clear liquids allowed Avoid sweetened beverages Sip very slowly No straws Avoid caffeinated carbonated and alcoholic beverages STOP drinking if you feel fullness pain or discomfort

Protein supplements

Begin the day after you go home from Hospital

Minimum protein target 70gmsday

May use powder or pre-mixed liquid forms (Whey protein is preferred)

Protein pills may not be used

Vitamin and Mineral Supplements

Gastric bypass patients In addition to eating much less food gastric bypass patients will also

absorb vitamins and minerals differently after surgery They will require daily multivitamin calcium and iron

supplementation for the rest of your life

Vitamin and Mineral Supplements

Lap-Bandreg patients

Require a multivitamin with minerals daily

It may be necessary to take additional vitamins and minerals eg calcium iron folateB1 B12These will be prescribed as needed

Stage 2 dietPUREE

Puree diet

Regular scheduled meals Avoid meal skipping Plan meals in advance Eat Slowly Eat protein foods first Moisten meats Use liquid protein as supplement not as meal replacement

Measure 2 oz portions at each meal eating when full Separate liquids and solids No bread rice or pasta Avoid added sugars and high fat

foods VARIETY

Advantages

No intestinal surgery No staplingcutting of stomach No nutritional risks Adjustable Reversible Safe

Foreign body Frequent follow-up visits Needs more commitment Easy to cheat

Disadvantages

Comparison of Adjustable Gastric Banding and Vertical Banded Gastroplasty

Laparoscopic adjustable gastric banding Reversible Adjustable Simpler to perform laparoscopically Sustained weight loss of gt50 EBW gt5

years following surgery Complications Gastric prolapse band

erosion rarely gastric perforation and access port complications

Vertical banded gastroplasty Irreversible Non adjustable Technically difficult by laparoscopy Weight loss of 25-50 EBW and weight gain

after 2-3 years Complications suture line disruption gastric

leak weight gain

>

>

Originally used as the first-stage operation for a proposed biliopancreatic diversion with duodenal switch in high-risk patients

The sleeve gastrectomy has caught on as a primary obesity treatment as surgeons are reporting weight loss of 55 of excess body weight past 5 years in some patients

The sleeve gastrectomy is also known as the greater curvature gastrectomy vertical or longitudinal gastrectomy or Pylorus preserving lsquogastric tube creationrsquo

Rapid and less traumatic operation Good resolution of co-morbidities and good weight loss

A further second surgical step is then easily feasible if necessary

SLEEVE GASTRECTOMY

SLEEVE GASTRECTOMY

A sleeve gastrectomy involves resection of

approximately 80 of the greater curvature

side of the stomach

Smaller tubular gastric ldquosleeverdquo created

along the lesser curve that is based on the

lesser curvature blood supply

Ideal approximate capacity of the stomach

after the procedure is about 30- 60 ml pouch

1MECHANICAL RESTRICTION by reducing the volume of the stomach and impairing stomach mobility Also called lsquoFood limitingrsquo operation

2HORMONAL MODIFICATION by removing a great part of the Ghrelin (Hunger Hormone) production tissue

(Ghrelin is a 28 amino-acid-peptide secreted by the oxyntic glands of the gastric fungus It is a potent orexigenic (appetite-stimulating) peptide mediated by the activation of its receptors in the hypothalamus or pituitary area)

The gastric fundus contains 10 to 20 times more ghrelin per one gram of tissue than the duodenum In the SG resection of the fundus removes the major portion of ghrelin release therefore appetite decreases

The sleeve gastrectomy (SG) induces weight loss by 2 mechanisms

>

Intragastric balloon involves placing a deflated balloon into the stomach and then filling it to decrease the amount of gastric space

The balloon can be left in the stomach for a maximum of 6 months and results in an average weight loss of 5ndash9 BMI over half a year

Done endoscopically

The intragastric balloon may be used prior to another bariatric surgery as a step-down procedure

INTRA GASTRIC BALLOON

>

>

The EndoBarrier gastrointestinal liner mimics the effects of gastric bypass surgery

Itrsquos designed to work by inserting a flexible

tube-like barrier into the duodenum amp 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

ENDO BARRIER LINER SYSTEM

B MAL- ABSORPTIVE PROCEDURES

Malabsorptive surgeries rearrange andor remove part of digestive system which then limits the amount of calories and nutrients that body can absorb Treatment with a large malabsorptive component results in the most weight loss but tend to have slightly higher complication rates

1JEJUNAL ILEAL BYPASS ndash no longer performed for high complication rates

2ILEAL TRANSPOSITION- New malabsoptive procedure on trial for treatment of DM type 2 and metabolic disorders

C COMBINATION PROCEDURES RESTRICTIVE + MALABSORBTIVE

1LAP GASTRIC BYPASS ndash ROUX-EN- Y ndash more malabsorption than the restrictive

2MINI- GASTRIC BYPASS- mainly restrictive

3DUODENAL SWITCH ndash the sleeve stomach is the restrictive portion ampthe intestinal bypass (duodenal switch) is the malabsorptive component

When surgery combines both restrictive and malabsorptive techniques it is know as a ldquocombinationrdquo procedure Most types of bariatric surgery carry at least a small element of both components but the following surgeries achieve a notable portion of weight loss from eachhellip

1 LAP GASTRIC BYPASS LGB

The Roux-en-Y gastric bypass(known simply as the LRYGBP) is the most commonly performed procedure

It primarily causesweight loss by restricting thefood intake however there ismore amount of mal absorption that occurs with this operation

GASTRIC BYPASS LRYGBP

bullThe stomach is stapled into2 pieces one small and one large The small piece becomes the ldquonewrdquo stomach pouch

bull The larger portion of the stomach stays in place however will lie dormant for the remainder of the patientrsquos life

GASTRIC BYPASS LGB

bull The small intestine (the jejunum) is divided using a surgical staplerApprox 50-70 cm from the DJ Junction

GASTRIC BYPASS LGB

Y- LIMB BP LIMB

bull The end of the Roux limb is then attached to the newly formed stomach pouch which carries food to the distal intestine

bull The Roux loop is completed by forming a jejunostomy

bull The Y limb or BPD limb carries digestive juices from the pancreas gall bladder liver and duodenum to the intestines

bull The food and the digestive juices mix where the Roux limb and Y limb meet much below say 100-150 cm from DJ

Roux limb or alimentary limb

100-150 cm

How Does the Roux-en-Y Work

Surgery factors restriction of meal size ldquodumping syndromerdquo some malabsorption decreased appetite

Patient factors calorie intake calorie expenditure

bull Most commonly performedbull Most reliable operation for long term weight lossbull Long term weight loss averages 60 to 75 percent of EBWbull Malnutrition is unusualbull Substantial improvement amp resolution in many co-morbid

obesity conditions

ADVANTAGES OF RYGBP

1 Not reversible

2 Mortality 05- 1

3 Perioperative complications 5-10

4 Stricture of gastrojejunostomy-10 (long term)

5 Long term risk of protein amp vitamin deficiency and marginal ulceration of GJA

6Long term risk of intestinal obstruction ndash 2

LAPAROSCOPIC GASTRIC BYPASSCOMPLICATIONS

Biliopancreatic Diversion (BPD)

Primarily malabsorptive but restrictive component also

First Terminal ileum is measured to a length of 50 cms marked with suture

The alimentary tract beyond the proximal part of stomach is rearranged to

include only distal 200 cm of ileum including common channel

Common channel-Distal 50 cm of terminal ileum for absorption of fat and

protein

The proximal end of ileum anastomosed to proximal end of stomach after

performing distal hemigastrectomy

Biliopancreatic Diversion with Duodenal Switch

Modification to lessen high incidence of vit b12 deficiency anastomotic stricture at gastrojejunal anastomosis

This procedure involves a sleeve gastrectomy that is then diverted at the duodenum into the ileum at a point measured proximally from the ileocecal valve (usually 250 cm)

The distal duodenum and jejunum the biliopancreatic limb are then anastomosed to the ileum at a point measured proximally from the ileocecal valve (usually 100 cm)

Common channel is 100cm Entire alimentary tract is 250 cm This is the most aggressive bypass procedure commonly offered today Major difference-Sleeve gastrectomy instead of distal hemigastrectomy

bull Most women regained normal menstrual function and most had documented

spontaneous ovulation

bull Significant improvement in hirsutism androgen profiles and about a 50 reduction in

HOMA-IR

bull Follow up for more than 2 years showed that all women resumed normal menstrual

cycles HbA1C decreased from 82 to 51 in lt 3 months

bull 78 saw improvement in metabolic syndrome amp 48 showed improvement in PCOS

2 ROLE OF BARIATRIC SURGERY IN PCOS PATIENTS

bull Decrease menstrual irregularities bull PCOS women have less hyper androgenism

bull Sex hormone binding globulin increases bull LH and FSH levels have been reported to increase

bull Ovulatory function measured by luteal LH and Progesterone secretion improved bull Leptin levels decrease reflecting improved reproductive metabolic status

bull Subclinical hypothyroidism significantly reduced

THE SAFE TIMING OF PREGNANCYoptimal or minimal time gt12 months after bariatric surgery before becoming pregnant in order to allow the rapid weight loss and metabolic changes to subside

4 BARIATRIC SURGERY IN REPRODUCTIVE WOMEN

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)

The foregut hypothesis theory ndash 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

Effect of Bariatric Surgery on Diabetes Mellitus

Combined Gastric Restriction amp Malabsorption

Operative Risks (vs cholecystectomy)

Perioperative Mortality 1-2 vs 02-08 Early Complications 10 vs 29Late Complications 20 vs 1-2

LimitationsWidening of (unbanded) gastrojejunostomyExpansion of gastric pouch 25 with nearly 100 weight regainAdaptation of limb that receives the food

SUMMARY OF ALL TYPES OF SURGERY

bull LRYGBP ndash worlds best procedure 60-70 WL dumping syndrome malnutrition

bull LAGB- low complications varying range of wt loss frequent post-op visits ( 10)

bull DSBPD- more wt loss high complications good for high BMI gt 50 malabsorption +

bull VBG(vertical band gastroplasty) ndash longest available results good wt loss improved co-morbidities right for some ptsrisks too high to justify rewards

bull SG- needs long term research 1st step procedure low risks higher wt loss lesser complications pouch could Stretch over time long staple line could cause problems in future frequency is accelerating because of technical ease 1st stage procedure before bypass

Post-surgical Complications

Anastomosis leaks or staple line leaks Pulmonary Embolism or DVT Cholelithiasis Stomal ulceration Dumping syndrome Constipation

Anastamosis Leaks

Up to 7-10 days after surgery Most common at gastrojejunostomy enteroenterostomy Roux

limb stump staple line Can lead to peritonitis sepsis possible death Presentation

Tachycardia tachypnea Fever Ab painback pain Pelvic pressure or rebound tenderness

Anastamosis Leaks

Order Gastrograffin upper GI series Subclinical cases

Bowel rest Parenteral nutrition IV antibiotic if H pylori

Clinically suspect leak Laparoscopic evaluation and leak repair

Failure to evaluate is the most common cause of preventable major long-term disability or death in bariatric surgical patients

Pulmonary Embolism

Sudden cause of death up to one month after surgery 20-30 mortality rate High risk may have vena cava filter placement prior to surgery Prophylaxis with compression stockings and LMWH Early ambulation imperitive

Pulmonary Embolism

Presentation Profound hypoxia Hypotension Signs of sepsis

Immediate spiral chest CT Abdominal exploration if too large for machine No pathology start anticoagulation Too largehelliphellipNO SURGERY

Cholelithiasis

Up to 36 of patients within 6 months post-op Bile stasis leads to increased sludge and gallstones Prophylactic cholecystectomy prior to surgery if

evidence of existing sludge or stones Prevent post-operative disease with concurrent bariatric

surgery and cholecystectomy Prophylactic use of urosidol

Expensive and unpalatable

Stomal Ulceration

12-15 within 2-4 mos Post-surgery Etiology

Overabundant acid in pouch leads to excessive acid passing through stoma

Pouch tension and staple line breakdown NSAID use

Presentation Dyspepsia vomiting Epigastric or retrosternal pain

Stomal Ulceration

Treatment PPI carafate Antibiotics if H Pylori Avoid NSAIDS alcohol smoking

If no response to treatment Endoscopy Back to surgery for pouch revision or staple line repair

Dumping Syndrome

More than 15 patients Hypotention Tachycardia Lightheadedness syncope Flushing Abdominal cramping and diarrhea Nausea and vomiting

Dumping Syndrome

Occurs with high dose simple sugar ingestion Sugar in small intestine causes osmotic overload and fluid

shift from blood to intestine Increased intestinal volume leads to watery diarrhea Decreased blood volume leads to systemic changes Patient education

Eat slowly Avoid drinking before during and not until 30 minutes after meals

Constipation

Most common complaint Causes

Dehydration and decreased fluid intake post-operatively Increased metabolic water needs Calcium and iron supplement use following surgery

Treat with increased fluids and stool softeners

Nutritional Consequences

Iron deficiency anemia B12 deficiency Folate deficiency Calcium and Vitamin D deficiency

Not seen with purely restrictive surgeries

Iron deficiency and anemia

Common following RYGB As high as 49 of patients Multifactorial cause

Low gastric acid levels prohibit iron cleavage from food Absorption inhibited because no nutrient exposure to duodenum or

proximal jejunum Decrease in iron-rich food consumption due to intolerance

Treat with oral supplementation of ferrous sulfate or ferrous gluconate

Vitamin B12 deficiency

Up to 70 of patients Lack of hydrochloric acid and pepsin in stomach

Prevents B12 cleavage from food Affects secretion of intrinsic factor thus B12 absorption

Intolerance to meat and milk Oral supplementation usually adequate otherwise IM injections used

Folate Deficiency

40 of gastric bypass patients Complete absorption requires B12 Absorption dependent on HCl and upper 13 stomach Deficiency generally caused by decreased consumption Oral supplementation

Vitamin D and Calcium Deficiency

Vitamin D deficiency is common among obese people Calcium absorption decreased because duodenum is

bypassed Intolerance to dairy foods high in calcium Vitamin D is required for Ca++ absorption Prolonged deficiencies lead to

Bone resorption osteomalacia osteoporosis Treat with calcium citrate supplementation and 2 weekly

doses of Vitamin D

Nutritional Implications of Various Bariatric Surgeries(34)

bull RYGB Malabsorption of Vit B12 Vit B1 (thiamin) Vit D Vit K Folate Iron Calcium

bull LAGB Folic Acid deficiency

bull BPD and BPDDS Vit A D E and K deficiency Protein-Calorie Malnutrition Malabsorption of

Calcium Zinc Selenium Sodium Potassium Chloride Phosphorus Magnesium

Recommended Daily Supplements(4)

Multivitamin with iron (prenatal vitamin will have adeq amount of folic acid)

Calcium (citrate) with vitamin D (1200-1500 mg calcium with 800-1000 IU vitamin D)

Oral vitamin B12 (500-1000 mcg) Iron (65 mgday in elemental form)

Vitamin C (to increase absorption of Iron) Thiamin (10 mgday)

Diet Recommendations(3)

Reduce food volume Chew food very well Slow pace of eating No liquids with meals Encourage fruits and vegetables as diet progresses Include high protein foods (at least 60gday) may need protein

supplements

Diet Progression Gastric Bypass

Stage 1 Clear liquids and protein supplement (1 week)

Stage 2No concentrated sweets low fat puree diet ( 3 weeks)

Stage 3 Regular texture weight reduction diet

Diet Progression Lap - Band

Stage 1 Clear liquids and protein supplement ( 2 weeks)

Stage 2 No concentrated sweets low fat puree diet (2weeks)

Stage 3 Regular texture weight reduction diet

Stage 1

Only clear liquids allowed Avoid sweetened beverages Sip very slowly No straws Avoid caffeinated carbonated and alcoholic beverages STOP drinking if you feel fullness pain or discomfort

Protein supplements

Begin the day after you go home from Hospital

Minimum protein target 70gmsday

May use powder or pre-mixed liquid forms (Whey protein is preferred)

Protein pills may not be used

Vitamin and Mineral Supplements

Gastric bypass patients In addition to eating much less food gastric bypass patients will also

absorb vitamins and minerals differently after surgery They will require daily multivitamin calcium and iron

supplementation for the rest of your life

Vitamin and Mineral Supplements

Lap-Bandreg patients

Require a multivitamin with minerals daily

It may be necessary to take additional vitamins and minerals eg calcium iron folateB1 B12These will be prescribed as needed

Stage 2 dietPUREE

Puree diet

Regular scheduled meals Avoid meal skipping Plan meals in advance Eat Slowly Eat protein foods first Moisten meats Use liquid protein as supplement not as meal replacement

Measure 2 oz portions at each meal eating when full Separate liquids and solids No bread rice or pasta Avoid added sugars and high fat

foods VARIETY

Comparison of Adjustable Gastric Banding and Vertical Banded Gastroplasty

Laparoscopic adjustable gastric banding Reversible Adjustable Simpler to perform laparoscopically Sustained weight loss of gt50 EBW gt5

years following surgery Complications Gastric prolapse band

erosion rarely gastric perforation and access port complications

Vertical banded gastroplasty Irreversible Non adjustable Technically difficult by laparoscopy Weight loss of 25-50 EBW and weight gain

after 2-3 years Complications suture line disruption gastric

leak weight gain

>

>

Originally used as the first-stage operation for a proposed biliopancreatic diversion with duodenal switch in high-risk patients

The sleeve gastrectomy has caught on as a primary obesity treatment as surgeons are reporting weight loss of 55 of excess body weight past 5 years in some patients

The sleeve gastrectomy is also known as the greater curvature gastrectomy vertical or longitudinal gastrectomy or Pylorus preserving lsquogastric tube creationrsquo

Rapid and less traumatic operation Good resolution of co-morbidities and good weight loss

A further second surgical step is then easily feasible if necessary

SLEEVE GASTRECTOMY

SLEEVE GASTRECTOMY

A sleeve gastrectomy involves resection of

approximately 80 of the greater curvature

side of the stomach

Smaller tubular gastric ldquosleeverdquo created

along the lesser curve that is based on the

lesser curvature blood supply

Ideal approximate capacity of the stomach

after the procedure is about 30- 60 ml pouch

1MECHANICAL RESTRICTION by reducing the volume of the stomach and impairing stomach mobility Also called lsquoFood limitingrsquo operation

2HORMONAL MODIFICATION by removing a great part of the Ghrelin (Hunger Hormone) production tissue

(Ghrelin is a 28 amino-acid-peptide secreted by the oxyntic glands of the gastric fungus It is a potent orexigenic (appetite-stimulating) peptide mediated by the activation of its receptors in the hypothalamus or pituitary area)

The gastric fundus contains 10 to 20 times more ghrelin per one gram of tissue than the duodenum In the SG resection of the fundus removes the major portion of ghrelin release therefore appetite decreases

The sleeve gastrectomy (SG) induces weight loss by 2 mechanisms

>

Intragastric balloon involves placing a deflated balloon into the stomach and then filling it to decrease the amount of gastric space

The balloon can be left in the stomach for a maximum of 6 months and results in an average weight loss of 5ndash9 BMI over half a year

Done endoscopically

The intragastric balloon may be used prior to another bariatric surgery as a step-down procedure

INTRA GASTRIC BALLOON

>

>

The EndoBarrier gastrointestinal liner mimics the effects of gastric bypass surgery

Itrsquos designed to work by inserting a flexible

tube-like barrier into the duodenum amp 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

ENDO BARRIER LINER SYSTEM

B MAL- ABSORPTIVE PROCEDURES

Malabsorptive surgeries rearrange andor remove part of digestive system which then limits the amount of calories and nutrients that body can absorb Treatment with a large malabsorptive component results in the most weight loss but tend to have slightly higher complication rates

1JEJUNAL ILEAL BYPASS ndash no longer performed for high complication rates

2ILEAL TRANSPOSITION- New malabsoptive procedure on trial for treatment of DM type 2 and metabolic disorders

C COMBINATION PROCEDURES RESTRICTIVE + MALABSORBTIVE

1LAP GASTRIC BYPASS ndash ROUX-EN- Y ndash more malabsorption than the restrictive

2MINI- GASTRIC BYPASS- mainly restrictive

3DUODENAL SWITCH ndash the sleeve stomach is the restrictive portion ampthe intestinal bypass (duodenal switch) is the malabsorptive component

When surgery combines both restrictive and malabsorptive techniques it is know as a ldquocombinationrdquo procedure Most types of bariatric surgery carry at least a small element of both components but the following surgeries achieve a notable portion of weight loss from eachhellip

1 LAP GASTRIC BYPASS LGB

The Roux-en-Y gastric bypass(known simply as the LRYGBP) is the most commonly performed procedure

It primarily causesweight loss by restricting thefood intake however there ismore amount of mal absorption that occurs with this operation

GASTRIC BYPASS LRYGBP

bullThe stomach is stapled into2 pieces one small and one large The small piece becomes the ldquonewrdquo stomach pouch

bull The larger portion of the stomach stays in place however will lie dormant for the remainder of the patientrsquos life

GASTRIC BYPASS LGB

bull The small intestine (the jejunum) is divided using a surgical staplerApprox 50-70 cm from the DJ Junction

GASTRIC BYPASS LGB

Y- LIMB BP LIMB

bull The end of the Roux limb is then attached to the newly formed stomach pouch which carries food to the distal intestine

bull The Roux loop is completed by forming a jejunostomy

bull The Y limb or BPD limb carries digestive juices from the pancreas gall bladder liver and duodenum to the intestines

bull The food and the digestive juices mix where the Roux limb and Y limb meet much below say 100-150 cm from DJ

Roux limb or alimentary limb

100-150 cm

How Does the Roux-en-Y Work

Surgery factors restriction of meal size ldquodumping syndromerdquo some malabsorption decreased appetite

Patient factors calorie intake calorie expenditure

bull Most commonly performedbull Most reliable operation for long term weight lossbull Long term weight loss averages 60 to 75 percent of EBWbull Malnutrition is unusualbull Substantial improvement amp resolution in many co-morbid

obesity conditions

ADVANTAGES OF RYGBP

1 Not reversible

2 Mortality 05- 1

3 Perioperative complications 5-10

4 Stricture of gastrojejunostomy-10 (long term)

5 Long term risk of protein amp vitamin deficiency and marginal ulceration of GJA

6Long term risk of intestinal obstruction ndash 2

LAPAROSCOPIC GASTRIC BYPASSCOMPLICATIONS

Biliopancreatic Diversion (BPD)

Primarily malabsorptive but restrictive component also

First Terminal ileum is measured to a length of 50 cms marked with suture

The alimentary tract beyond the proximal part of stomach is rearranged to

include only distal 200 cm of ileum including common channel

Common channel-Distal 50 cm of terminal ileum for absorption of fat and

protein

The proximal end of ileum anastomosed to proximal end of stomach after

performing distal hemigastrectomy

Biliopancreatic Diversion with Duodenal Switch

Modification to lessen high incidence of vit b12 deficiency anastomotic stricture at gastrojejunal anastomosis

This procedure involves a sleeve gastrectomy that is then diverted at the duodenum into the ileum at a point measured proximally from the ileocecal valve (usually 250 cm)

The distal duodenum and jejunum the biliopancreatic limb are then anastomosed to the ileum at a point measured proximally from the ileocecal valve (usually 100 cm)

Common channel is 100cm Entire alimentary tract is 250 cm This is the most aggressive bypass procedure commonly offered today Major difference-Sleeve gastrectomy instead of distal hemigastrectomy

bull Most women regained normal menstrual function and most had documented

spontaneous ovulation

bull Significant improvement in hirsutism androgen profiles and about a 50 reduction in

HOMA-IR

bull Follow up for more than 2 years showed that all women resumed normal menstrual

cycles HbA1C decreased from 82 to 51 in lt 3 months

bull 78 saw improvement in metabolic syndrome amp 48 showed improvement in PCOS

2 ROLE OF BARIATRIC SURGERY IN PCOS PATIENTS

bull Decrease menstrual irregularities bull PCOS women have less hyper androgenism

bull Sex hormone binding globulin increases bull LH and FSH levels have been reported to increase

bull Ovulatory function measured by luteal LH and Progesterone secretion improved bull Leptin levels decrease reflecting improved reproductive metabolic status

bull Subclinical hypothyroidism significantly reduced

THE SAFE TIMING OF PREGNANCYoptimal or minimal time gt12 months after bariatric surgery before becoming pregnant in order to allow the rapid weight loss and metabolic changes to subside

4 BARIATRIC SURGERY IN REPRODUCTIVE WOMEN

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)

The foregut hypothesis theory ndash 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

Effect of Bariatric Surgery on Diabetes Mellitus

Combined Gastric Restriction amp Malabsorption

Operative Risks (vs cholecystectomy)

Perioperative Mortality 1-2 vs 02-08 Early Complications 10 vs 29Late Complications 20 vs 1-2

LimitationsWidening of (unbanded) gastrojejunostomyExpansion of gastric pouch 25 with nearly 100 weight regainAdaptation of limb that receives the food

SUMMARY OF ALL TYPES OF SURGERY

bull LRYGBP ndash worlds best procedure 60-70 WL dumping syndrome malnutrition

bull LAGB- low complications varying range of wt loss frequent post-op visits ( 10)

bull DSBPD- more wt loss high complications good for high BMI gt 50 malabsorption +

bull VBG(vertical band gastroplasty) ndash longest available results good wt loss improved co-morbidities right for some ptsrisks too high to justify rewards

bull SG- needs long term research 1st step procedure low risks higher wt loss lesser complications pouch could Stretch over time long staple line could cause problems in future frequency is accelerating because of technical ease 1st stage procedure before bypass

Post-surgical Complications

Anastomosis leaks or staple line leaks Pulmonary Embolism or DVT Cholelithiasis Stomal ulceration Dumping syndrome Constipation

Anastamosis Leaks

Up to 7-10 days after surgery Most common at gastrojejunostomy enteroenterostomy Roux

limb stump staple line Can lead to peritonitis sepsis possible death Presentation

Tachycardia tachypnea Fever Ab painback pain Pelvic pressure or rebound tenderness

Anastamosis Leaks

Order Gastrograffin upper GI series Subclinical cases

Bowel rest Parenteral nutrition IV antibiotic if H pylori

Clinically suspect leak Laparoscopic evaluation and leak repair

Failure to evaluate is the most common cause of preventable major long-term disability or death in bariatric surgical patients

Pulmonary Embolism

Sudden cause of death up to one month after surgery 20-30 mortality rate High risk may have vena cava filter placement prior to surgery Prophylaxis with compression stockings and LMWH Early ambulation imperitive

Pulmonary Embolism

Presentation Profound hypoxia Hypotension Signs of sepsis

Immediate spiral chest CT Abdominal exploration if too large for machine No pathology start anticoagulation Too largehelliphellipNO SURGERY

Cholelithiasis

Up to 36 of patients within 6 months post-op Bile stasis leads to increased sludge and gallstones Prophylactic cholecystectomy prior to surgery if

evidence of existing sludge or stones Prevent post-operative disease with concurrent bariatric

surgery and cholecystectomy Prophylactic use of urosidol

Expensive and unpalatable

Stomal Ulceration

12-15 within 2-4 mos Post-surgery Etiology

Overabundant acid in pouch leads to excessive acid passing through stoma

Pouch tension and staple line breakdown NSAID use

Presentation Dyspepsia vomiting Epigastric or retrosternal pain

Stomal Ulceration

Treatment PPI carafate Antibiotics if H Pylori Avoid NSAIDS alcohol smoking

If no response to treatment Endoscopy Back to surgery for pouch revision or staple line repair

Dumping Syndrome

More than 15 patients Hypotention Tachycardia Lightheadedness syncope Flushing Abdominal cramping and diarrhea Nausea and vomiting

Dumping Syndrome

Occurs with high dose simple sugar ingestion Sugar in small intestine causes osmotic overload and fluid

shift from blood to intestine Increased intestinal volume leads to watery diarrhea Decreased blood volume leads to systemic changes Patient education

Eat slowly Avoid drinking before during and not until 30 minutes after meals

Constipation

Most common complaint Causes

Dehydration and decreased fluid intake post-operatively Increased metabolic water needs Calcium and iron supplement use following surgery

Treat with increased fluids and stool softeners

Nutritional Consequences

Iron deficiency anemia B12 deficiency Folate deficiency Calcium and Vitamin D deficiency

Not seen with purely restrictive surgeries

Iron deficiency and anemia

Common following RYGB As high as 49 of patients Multifactorial cause

Low gastric acid levels prohibit iron cleavage from food Absorption inhibited because no nutrient exposure to duodenum or

proximal jejunum Decrease in iron-rich food consumption due to intolerance

Treat with oral supplementation of ferrous sulfate or ferrous gluconate

Vitamin B12 deficiency

Up to 70 of patients Lack of hydrochloric acid and pepsin in stomach

Prevents B12 cleavage from food Affects secretion of intrinsic factor thus B12 absorption

Intolerance to meat and milk Oral supplementation usually adequate otherwise IM injections used

Folate Deficiency

40 of gastric bypass patients Complete absorption requires B12 Absorption dependent on HCl and upper 13 stomach Deficiency generally caused by decreased consumption Oral supplementation

Vitamin D and Calcium Deficiency

Vitamin D deficiency is common among obese people Calcium absorption decreased because duodenum is

bypassed Intolerance to dairy foods high in calcium Vitamin D is required for Ca++ absorption Prolonged deficiencies lead to

Bone resorption osteomalacia osteoporosis Treat with calcium citrate supplementation and 2 weekly

doses of Vitamin D

Nutritional Implications of Various Bariatric Surgeries(34)

bull RYGB Malabsorption of Vit B12 Vit B1 (thiamin) Vit D Vit K Folate Iron Calcium

bull LAGB Folic Acid deficiency

bull BPD and BPDDS Vit A D E and K deficiency Protein-Calorie Malnutrition Malabsorption of

Calcium Zinc Selenium Sodium Potassium Chloride Phosphorus Magnesium

Recommended Daily Supplements(4)

Multivitamin with iron (prenatal vitamin will have adeq amount of folic acid)

Calcium (citrate) with vitamin D (1200-1500 mg calcium with 800-1000 IU vitamin D)

Oral vitamin B12 (500-1000 mcg) Iron (65 mgday in elemental form)

Vitamin C (to increase absorption of Iron) Thiamin (10 mgday)

Diet Recommendations(3)

Reduce food volume Chew food very well Slow pace of eating No liquids with meals Encourage fruits and vegetables as diet progresses Include high protein foods (at least 60gday) may need protein

supplements

Diet Progression Gastric Bypass

Stage 1 Clear liquids and protein supplement (1 week)

Stage 2No concentrated sweets low fat puree diet ( 3 weeks)

Stage 3 Regular texture weight reduction diet

Diet Progression Lap - Band

Stage 1 Clear liquids and protein supplement ( 2 weeks)

Stage 2 No concentrated sweets low fat puree diet (2weeks)

Stage 3 Regular texture weight reduction diet

Stage 1

Only clear liquids allowed Avoid sweetened beverages Sip very slowly No straws Avoid caffeinated carbonated and alcoholic beverages STOP drinking if you feel fullness pain or discomfort

Protein supplements

Begin the day after you go home from Hospital

Minimum protein target 70gmsday

May use powder or pre-mixed liquid forms (Whey protein is preferred)

Protein pills may not be used

Vitamin and Mineral Supplements

Gastric bypass patients In addition to eating much less food gastric bypass patients will also

absorb vitamins and minerals differently after surgery They will require daily multivitamin calcium and iron

supplementation for the rest of your life

Vitamin and Mineral Supplements

Lap-Bandreg patients

Require a multivitamin with minerals daily

It may be necessary to take additional vitamins and minerals eg calcium iron folateB1 B12These will be prescribed as needed

Stage 2 dietPUREE

Puree diet

Regular scheduled meals Avoid meal skipping Plan meals in advance Eat Slowly Eat protein foods first Moisten meats Use liquid protein as supplement not as meal replacement

Measure 2 oz portions at each meal eating when full Separate liquids and solids No bread rice or pasta Avoid added sugars and high fat

foods VARIETY

>

>

Originally used as the first-stage operation for a proposed biliopancreatic diversion with duodenal switch in high-risk patients

The sleeve gastrectomy has caught on as a primary obesity treatment as surgeons are reporting weight loss of 55 of excess body weight past 5 years in some patients

The sleeve gastrectomy is also known as the greater curvature gastrectomy vertical or longitudinal gastrectomy or Pylorus preserving lsquogastric tube creationrsquo

Rapid and less traumatic operation Good resolution of co-morbidities and good weight loss

A further second surgical step is then easily feasible if necessary

SLEEVE GASTRECTOMY

SLEEVE GASTRECTOMY

A sleeve gastrectomy involves resection of

approximately 80 of the greater curvature

side of the stomach

Smaller tubular gastric ldquosleeverdquo created

along the lesser curve that is based on the

lesser curvature blood supply

Ideal approximate capacity of the stomach

after the procedure is about 30- 60 ml pouch

1MECHANICAL RESTRICTION by reducing the volume of the stomach and impairing stomach mobility Also called lsquoFood limitingrsquo operation

2HORMONAL MODIFICATION by removing a great part of the Ghrelin (Hunger Hormone) production tissue

(Ghrelin is a 28 amino-acid-peptide secreted by the oxyntic glands of the gastric fungus It is a potent orexigenic (appetite-stimulating) peptide mediated by the activation of its receptors in the hypothalamus or pituitary area)

The gastric fundus contains 10 to 20 times more ghrelin per one gram of tissue than the duodenum In the SG resection of the fundus removes the major portion of ghrelin release therefore appetite decreases

The sleeve gastrectomy (SG) induces weight loss by 2 mechanisms

>

Intragastric balloon involves placing a deflated balloon into the stomach and then filling it to decrease the amount of gastric space

The balloon can be left in the stomach for a maximum of 6 months and results in an average weight loss of 5ndash9 BMI over half a year

Done endoscopically

The intragastric balloon may be used prior to another bariatric surgery as a step-down procedure

INTRA GASTRIC BALLOON

>

>

The EndoBarrier gastrointestinal liner mimics the effects of gastric bypass surgery

Itrsquos designed to work by inserting a flexible

tube-like barrier into the duodenum amp 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

ENDO BARRIER LINER SYSTEM

B MAL- ABSORPTIVE PROCEDURES

Malabsorptive surgeries rearrange andor remove part of digestive system which then limits the amount of calories and nutrients that body can absorb Treatment with a large malabsorptive component results in the most weight loss but tend to have slightly higher complication rates

1JEJUNAL ILEAL BYPASS ndash no longer performed for high complication rates

2ILEAL TRANSPOSITION- New malabsoptive procedure on trial for treatment of DM type 2 and metabolic disorders

C COMBINATION PROCEDURES RESTRICTIVE + MALABSORBTIVE

1LAP GASTRIC BYPASS ndash ROUX-EN- Y ndash more malabsorption than the restrictive

2MINI- GASTRIC BYPASS- mainly restrictive

3DUODENAL SWITCH ndash the sleeve stomach is the restrictive portion ampthe intestinal bypass (duodenal switch) is the malabsorptive component

When surgery combines both restrictive and malabsorptive techniques it is know as a ldquocombinationrdquo procedure Most types of bariatric surgery carry at least a small element of both components but the following surgeries achieve a notable portion of weight loss from eachhellip

1 LAP GASTRIC BYPASS LGB

The Roux-en-Y gastric bypass(known simply as the LRYGBP) is the most commonly performed procedure

It primarily causesweight loss by restricting thefood intake however there ismore amount of mal absorption that occurs with this operation

GASTRIC BYPASS LRYGBP

bullThe stomach is stapled into2 pieces one small and one large The small piece becomes the ldquonewrdquo stomach pouch

bull The larger portion of the stomach stays in place however will lie dormant for the remainder of the patientrsquos life

GASTRIC BYPASS LGB

bull The small intestine (the jejunum) is divided using a surgical staplerApprox 50-70 cm from the DJ Junction

GASTRIC BYPASS LGB

Y- LIMB BP LIMB

bull The end of the Roux limb is then attached to the newly formed stomach pouch which carries food to the distal intestine

bull The Roux loop is completed by forming a jejunostomy

bull The Y limb or BPD limb carries digestive juices from the pancreas gall bladder liver and duodenum to the intestines

bull The food and the digestive juices mix where the Roux limb and Y limb meet much below say 100-150 cm from DJ

Roux limb or alimentary limb

100-150 cm

How Does the Roux-en-Y Work

Surgery factors restriction of meal size ldquodumping syndromerdquo some malabsorption decreased appetite

Patient factors calorie intake calorie expenditure

bull Most commonly performedbull Most reliable operation for long term weight lossbull Long term weight loss averages 60 to 75 percent of EBWbull Malnutrition is unusualbull Substantial improvement amp resolution in many co-morbid

obesity conditions

ADVANTAGES OF RYGBP

1 Not reversible

2 Mortality 05- 1

3 Perioperative complications 5-10

4 Stricture of gastrojejunostomy-10 (long term)

5 Long term risk of protein amp vitamin deficiency and marginal ulceration of GJA

6Long term risk of intestinal obstruction ndash 2

LAPAROSCOPIC GASTRIC BYPASSCOMPLICATIONS

Biliopancreatic Diversion (BPD)

Primarily malabsorptive but restrictive component also

First Terminal ileum is measured to a length of 50 cms marked with suture

The alimentary tract beyond the proximal part of stomach is rearranged to

include only distal 200 cm of ileum including common channel

Common channel-Distal 50 cm of terminal ileum for absorption of fat and

protein

The proximal end of ileum anastomosed to proximal end of stomach after

performing distal hemigastrectomy

Biliopancreatic Diversion with Duodenal Switch

Modification to lessen high incidence of vit b12 deficiency anastomotic stricture at gastrojejunal anastomosis

This procedure involves a sleeve gastrectomy that is then diverted at the duodenum into the ileum at a point measured proximally from the ileocecal valve (usually 250 cm)

The distal duodenum and jejunum the biliopancreatic limb are then anastomosed to the ileum at a point measured proximally from the ileocecal valve (usually 100 cm)

Common channel is 100cm Entire alimentary tract is 250 cm This is the most aggressive bypass procedure commonly offered today Major difference-Sleeve gastrectomy instead of distal hemigastrectomy

bull Most women regained normal menstrual function and most had documented

spontaneous ovulation

bull Significant improvement in hirsutism androgen profiles and about a 50 reduction in

HOMA-IR

bull Follow up for more than 2 years showed that all women resumed normal menstrual

cycles HbA1C decreased from 82 to 51 in lt 3 months

bull 78 saw improvement in metabolic syndrome amp 48 showed improvement in PCOS

2 ROLE OF BARIATRIC SURGERY IN PCOS PATIENTS

bull Decrease menstrual irregularities bull PCOS women have less hyper androgenism

bull Sex hormone binding globulin increases bull LH and FSH levels have been reported to increase

bull Ovulatory function measured by luteal LH and Progesterone secretion improved bull Leptin levels decrease reflecting improved reproductive metabolic status

bull Subclinical hypothyroidism significantly reduced

THE SAFE TIMING OF PREGNANCYoptimal or minimal time gt12 months after bariatric surgery before becoming pregnant in order to allow the rapid weight loss and metabolic changes to subside

4 BARIATRIC SURGERY IN REPRODUCTIVE WOMEN

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)

The foregut hypothesis theory ndash 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

Effect of Bariatric Surgery on Diabetes Mellitus

Combined Gastric Restriction amp Malabsorption

Operative Risks (vs cholecystectomy)

Perioperative Mortality 1-2 vs 02-08 Early Complications 10 vs 29Late Complications 20 vs 1-2

LimitationsWidening of (unbanded) gastrojejunostomyExpansion of gastric pouch 25 with nearly 100 weight regainAdaptation of limb that receives the food

SUMMARY OF ALL TYPES OF SURGERY

bull LRYGBP ndash worlds best procedure 60-70 WL dumping syndrome malnutrition

bull LAGB- low complications varying range of wt loss frequent post-op visits ( 10)

bull DSBPD- more wt loss high complications good for high BMI gt 50 malabsorption +

bull VBG(vertical band gastroplasty) ndash longest available results good wt loss improved co-morbidities right for some ptsrisks too high to justify rewards

bull SG- needs long term research 1st step procedure low risks higher wt loss lesser complications pouch could Stretch over time long staple line could cause problems in future frequency is accelerating because of technical ease 1st stage procedure before bypass

Post-surgical Complications

Anastomosis leaks or staple line leaks Pulmonary Embolism or DVT Cholelithiasis Stomal ulceration Dumping syndrome Constipation

Anastamosis Leaks

Up to 7-10 days after surgery Most common at gastrojejunostomy enteroenterostomy Roux

limb stump staple line Can lead to peritonitis sepsis possible death Presentation

Tachycardia tachypnea Fever Ab painback pain Pelvic pressure or rebound tenderness

Anastamosis Leaks

Order Gastrograffin upper GI series Subclinical cases

Bowel rest Parenteral nutrition IV antibiotic if H pylori

Clinically suspect leak Laparoscopic evaluation and leak repair

Failure to evaluate is the most common cause of preventable major long-term disability or death in bariatric surgical patients

Pulmonary Embolism

Sudden cause of death up to one month after surgery 20-30 mortality rate High risk may have vena cava filter placement prior to surgery Prophylaxis with compression stockings and LMWH Early ambulation imperitive

Pulmonary Embolism

Presentation Profound hypoxia Hypotension Signs of sepsis

Immediate spiral chest CT Abdominal exploration if too large for machine No pathology start anticoagulation Too largehelliphellipNO SURGERY

Cholelithiasis

Up to 36 of patients within 6 months post-op Bile stasis leads to increased sludge and gallstones Prophylactic cholecystectomy prior to surgery if

evidence of existing sludge or stones Prevent post-operative disease with concurrent bariatric

surgery and cholecystectomy Prophylactic use of urosidol

Expensive and unpalatable

Stomal Ulceration

12-15 within 2-4 mos Post-surgery Etiology

Overabundant acid in pouch leads to excessive acid passing through stoma

Pouch tension and staple line breakdown NSAID use

Presentation Dyspepsia vomiting Epigastric or retrosternal pain

Stomal Ulceration

Treatment PPI carafate Antibiotics if H Pylori Avoid NSAIDS alcohol smoking

If no response to treatment Endoscopy Back to surgery for pouch revision or staple line repair

Dumping Syndrome

More than 15 patients Hypotention Tachycardia Lightheadedness syncope Flushing Abdominal cramping and diarrhea Nausea and vomiting

Dumping Syndrome

Occurs with high dose simple sugar ingestion Sugar in small intestine causes osmotic overload and fluid

shift from blood to intestine Increased intestinal volume leads to watery diarrhea Decreased blood volume leads to systemic changes Patient education

Eat slowly Avoid drinking before during and not until 30 minutes after meals

Constipation

Most common complaint Causes

Dehydration and decreased fluid intake post-operatively Increased metabolic water needs Calcium and iron supplement use following surgery

Treat with increased fluids and stool softeners

Nutritional Consequences

Iron deficiency anemia B12 deficiency Folate deficiency Calcium and Vitamin D deficiency

Not seen with purely restrictive surgeries

Iron deficiency and anemia

Common following RYGB As high as 49 of patients Multifactorial cause

Low gastric acid levels prohibit iron cleavage from food Absorption inhibited because no nutrient exposure to duodenum or

proximal jejunum Decrease in iron-rich food consumption due to intolerance

Treat with oral supplementation of ferrous sulfate or ferrous gluconate

Vitamin B12 deficiency

Up to 70 of patients Lack of hydrochloric acid and pepsin in stomach

Prevents B12 cleavage from food Affects secretion of intrinsic factor thus B12 absorption

Intolerance to meat and milk Oral supplementation usually adequate otherwise IM injections used

Folate Deficiency

40 of gastric bypass patients Complete absorption requires B12 Absorption dependent on HCl and upper 13 stomach Deficiency generally caused by decreased consumption Oral supplementation

Vitamin D and Calcium Deficiency

Vitamin D deficiency is common among obese people Calcium absorption decreased because duodenum is

bypassed Intolerance to dairy foods high in calcium Vitamin D is required for Ca++ absorption Prolonged deficiencies lead to

Bone resorption osteomalacia osteoporosis Treat with calcium citrate supplementation and 2 weekly

doses of Vitamin D

Nutritional Implications of Various Bariatric Surgeries(34)

bull RYGB Malabsorption of Vit B12 Vit B1 (thiamin) Vit D Vit K Folate Iron Calcium

bull LAGB Folic Acid deficiency

bull BPD and BPDDS Vit A D E and K deficiency Protein-Calorie Malnutrition Malabsorption of

Calcium Zinc Selenium Sodium Potassium Chloride Phosphorus Magnesium

Recommended Daily Supplements(4)

Multivitamin with iron (prenatal vitamin will have adeq amount of folic acid)

Calcium (citrate) with vitamin D (1200-1500 mg calcium with 800-1000 IU vitamin D)

Oral vitamin B12 (500-1000 mcg) Iron (65 mgday in elemental form)

Vitamin C (to increase absorption of Iron) Thiamin (10 mgday)

Diet Recommendations(3)

Reduce food volume Chew food very well Slow pace of eating No liquids with meals Encourage fruits and vegetables as diet progresses Include high protein foods (at least 60gday) may need protein

supplements

Diet Progression Gastric Bypass

Stage 1 Clear liquids and protein supplement (1 week)

Stage 2No concentrated sweets low fat puree diet ( 3 weeks)

Stage 3 Regular texture weight reduction diet

Diet Progression Lap - Band

Stage 1 Clear liquids and protein supplement ( 2 weeks)

Stage 2 No concentrated sweets low fat puree diet (2weeks)

Stage 3 Regular texture weight reduction diet

Stage 1

Only clear liquids allowed Avoid sweetened beverages Sip very slowly No straws Avoid caffeinated carbonated and alcoholic beverages STOP drinking if you feel fullness pain or discomfort

Protein supplements

Begin the day after you go home from Hospital

Minimum protein target 70gmsday

May use powder or pre-mixed liquid forms (Whey protein is preferred)

Protein pills may not be used

Vitamin and Mineral Supplements

Gastric bypass patients In addition to eating much less food gastric bypass patients will also

absorb vitamins and minerals differently after surgery They will require daily multivitamin calcium and iron

supplementation for the rest of your life

Vitamin and Mineral Supplements

Lap-Bandreg patients

Require a multivitamin with minerals daily

It may be necessary to take additional vitamins and minerals eg calcium iron folateB1 B12These will be prescribed as needed

Stage 2 dietPUREE

Puree diet

Regular scheduled meals Avoid meal skipping Plan meals in advance Eat Slowly Eat protein foods first Moisten meats Use liquid protein as supplement not as meal replacement

Measure 2 oz portions at each meal eating when full Separate liquids and solids No bread rice or pasta Avoid added sugars and high fat

foods VARIETY

Originally used as the first-stage operation for a proposed biliopancreatic diversion with duodenal switch in high-risk patients

The sleeve gastrectomy has caught on as a primary obesity treatment as surgeons are reporting weight loss of 55 of excess body weight past 5 years in some patients

The sleeve gastrectomy is also known as the greater curvature gastrectomy vertical or longitudinal gastrectomy or Pylorus preserving lsquogastric tube creationrsquo

Rapid and less traumatic operation Good resolution of co-morbidities and good weight loss

A further second surgical step is then easily feasible if necessary

SLEEVE GASTRECTOMY

SLEEVE GASTRECTOMY

A sleeve gastrectomy involves resection of

approximately 80 of the greater curvature

side of the stomach

Smaller tubular gastric ldquosleeverdquo created

along the lesser curve that is based on the

lesser curvature blood supply

Ideal approximate capacity of the stomach

after the procedure is about 30- 60 ml pouch

1MECHANICAL RESTRICTION by reducing the volume of the stomach and impairing stomach mobility Also called lsquoFood limitingrsquo operation

2HORMONAL MODIFICATION by removing a great part of the Ghrelin (Hunger Hormone) production tissue

(Ghrelin is a 28 amino-acid-peptide secreted by the oxyntic glands of the gastric fungus It is a potent orexigenic (appetite-stimulating) peptide mediated by the activation of its receptors in the hypothalamus or pituitary area)

The gastric fundus contains 10 to 20 times more ghrelin per one gram of tissue than the duodenum In the SG resection of the fundus removes the major portion of ghrelin release therefore appetite decreases

The sleeve gastrectomy (SG) induces weight loss by 2 mechanisms

>

Intragastric balloon involves placing a deflated balloon into the stomach and then filling it to decrease the amount of gastric space

The balloon can be left in the stomach for a maximum of 6 months and results in an average weight loss of 5ndash9 BMI over half a year

Done endoscopically

The intragastric balloon may be used prior to another bariatric surgery as a step-down procedure

INTRA GASTRIC BALLOON

>

>

The EndoBarrier gastrointestinal liner mimics the effects of gastric bypass surgery

Itrsquos designed to work by inserting a flexible

tube-like barrier into the duodenum amp 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

ENDO BARRIER LINER SYSTEM

B MAL- ABSORPTIVE PROCEDURES

Malabsorptive surgeries rearrange andor remove part of digestive system which then limits the amount of calories and nutrients that body can absorb Treatment with a large malabsorptive component results in the most weight loss but tend to have slightly higher complication rates

1JEJUNAL ILEAL BYPASS ndash no longer performed for high complication rates

2ILEAL TRANSPOSITION- New malabsoptive procedure on trial for treatment of DM type 2 and metabolic disorders

C COMBINATION PROCEDURES RESTRICTIVE + MALABSORBTIVE

1LAP GASTRIC BYPASS ndash ROUX-EN- Y ndash more malabsorption than the restrictive

2MINI- GASTRIC BYPASS- mainly restrictive

3DUODENAL SWITCH ndash the sleeve stomach is the restrictive portion ampthe intestinal bypass (duodenal switch) is the malabsorptive component

When surgery combines both restrictive and malabsorptive techniques it is know as a ldquocombinationrdquo procedure Most types of bariatric surgery carry at least a small element of both components but the following surgeries achieve a notable portion of weight loss from eachhellip

1 LAP GASTRIC BYPASS LGB

The Roux-en-Y gastric bypass(known simply as the LRYGBP) is the most commonly performed procedure

It primarily causesweight loss by restricting thefood intake however there ismore amount of mal absorption that occurs with this operation

GASTRIC BYPASS LRYGBP

bullThe stomach is stapled into2 pieces one small and one large The small piece becomes the ldquonewrdquo stomach pouch

bull The larger portion of the stomach stays in place however will lie dormant for the remainder of the patientrsquos life

GASTRIC BYPASS LGB

bull The small intestine (the jejunum) is divided using a surgical staplerApprox 50-70 cm from the DJ Junction

GASTRIC BYPASS LGB

Y- LIMB BP LIMB

bull The end of the Roux limb is then attached to the newly formed stomach pouch which carries food to the distal intestine

bull The Roux loop is completed by forming a jejunostomy

bull The Y limb or BPD limb carries digestive juices from the pancreas gall bladder liver and duodenum to the intestines

bull The food and the digestive juices mix where the Roux limb and Y limb meet much below say 100-150 cm from DJ

Roux limb or alimentary limb

100-150 cm

How Does the Roux-en-Y Work

Surgery factors restriction of meal size ldquodumping syndromerdquo some malabsorption decreased appetite

Patient factors calorie intake calorie expenditure

bull Most commonly performedbull Most reliable operation for long term weight lossbull Long term weight loss averages 60 to 75 percent of EBWbull Malnutrition is unusualbull Substantial improvement amp resolution in many co-morbid

obesity conditions

ADVANTAGES OF RYGBP

1 Not reversible

2 Mortality 05- 1

3 Perioperative complications 5-10

4 Stricture of gastrojejunostomy-10 (long term)

5 Long term risk of protein amp vitamin deficiency and marginal ulceration of GJA

6Long term risk of intestinal obstruction ndash 2

LAPAROSCOPIC GASTRIC BYPASSCOMPLICATIONS

Biliopancreatic Diversion (BPD)

Primarily malabsorptive but restrictive component also

First Terminal ileum is measured to a length of 50 cms marked with suture

The alimentary tract beyond the proximal part of stomach is rearranged to

include only distal 200 cm of ileum including common channel

Common channel-Distal 50 cm of terminal ileum for absorption of fat and

protein

The proximal end of ileum anastomosed to proximal end of stomach after

performing distal hemigastrectomy

Biliopancreatic Diversion with Duodenal Switch

Modification to lessen high incidence of vit b12 deficiency anastomotic stricture at gastrojejunal anastomosis

This procedure involves a sleeve gastrectomy that is then diverted at the duodenum into the ileum at a point measured proximally from the ileocecal valve (usually 250 cm)

The distal duodenum and jejunum the biliopancreatic limb are then anastomosed to the ileum at a point measured proximally from the ileocecal valve (usually 100 cm)

Common channel is 100cm Entire alimentary tract is 250 cm This is the most aggressive bypass procedure commonly offered today Major difference-Sleeve gastrectomy instead of distal hemigastrectomy

bull Most women regained normal menstrual function and most had documented

spontaneous ovulation

bull Significant improvement in hirsutism androgen profiles and about a 50 reduction in

HOMA-IR

bull Follow up for more than 2 years showed that all women resumed normal menstrual

cycles HbA1C decreased from 82 to 51 in lt 3 months

bull 78 saw improvement in metabolic syndrome amp 48 showed improvement in PCOS

2 ROLE OF BARIATRIC SURGERY IN PCOS PATIENTS

bull Decrease menstrual irregularities bull PCOS women have less hyper androgenism

bull Sex hormone binding globulin increases bull LH and FSH levels have been reported to increase

bull Ovulatory function measured by luteal LH and Progesterone secretion improved bull Leptin levels decrease reflecting improved reproductive metabolic status

bull Subclinical hypothyroidism significantly reduced

THE SAFE TIMING OF PREGNANCYoptimal or minimal time gt12 months after bariatric surgery before becoming pregnant in order to allow the rapid weight loss and metabolic changes to subside

4 BARIATRIC SURGERY IN REPRODUCTIVE WOMEN

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)

The foregut hypothesis theory ndash 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

Effect of Bariatric Surgery on Diabetes Mellitus

Combined Gastric Restriction amp Malabsorption

Operative Risks (vs cholecystectomy)

Perioperative Mortality 1-2 vs 02-08 Early Complications 10 vs 29Late Complications 20 vs 1-2

LimitationsWidening of (unbanded) gastrojejunostomyExpansion of gastric pouch 25 with nearly 100 weight regainAdaptation of limb that receives the food

SUMMARY OF ALL TYPES OF SURGERY

bull LRYGBP ndash worlds best procedure 60-70 WL dumping syndrome malnutrition

bull LAGB- low complications varying range of wt loss frequent post-op visits ( 10)

bull DSBPD- more wt loss high complications good for high BMI gt 50 malabsorption +

bull VBG(vertical band gastroplasty) ndash longest available results good wt loss improved co-morbidities right for some ptsrisks too high to justify rewards

bull SG- needs long term research 1st step procedure low risks higher wt loss lesser complications pouch could Stretch over time long staple line could cause problems in future frequency is accelerating because of technical ease 1st stage procedure before bypass

Post-surgical Complications

Anastomosis leaks or staple line leaks Pulmonary Embolism or DVT Cholelithiasis Stomal ulceration Dumping syndrome Constipation

Anastamosis Leaks

Up to 7-10 days after surgery Most common at gastrojejunostomy enteroenterostomy Roux

limb stump staple line Can lead to peritonitis sepsis possible death Presentation

Tachycardia tachypnea Fever Ab painback pain Pelvic pressure or rebound tenderness

Anastamosis Leaks

Order Gastrograffin upper GI series Subclinical cases

Bowel rest Parenteral nutrition IV antibiotic if H pylori

Clinically suspect leak Laparoscopic evaluation and leak repair

Failure to evaluate is the most common cause of preventable major long-term disability or death in bariatric surgical patients

Pulmonary Embolism

Sudden cause of death up to one month after surgery 20-30 mortality rate High risk may have vena cava filter placement prior to surgery Prophylaxis with compression stockings and LMWH Early ambulation imperitive

Pulmonary Embolism

Presentation Profound hypoxia Hypotension Signs of sepsis

Immediate spiral chest CT Abdominal exploration if too large for machine No pathology start anticoagulation Too largehelliphellipNO SURGERY

Cholelithiasis

Up to 36 of patients within 6 months post-op Bile stasis leads to increased sludge and gallstones Prophylactic cholecystectomy prior to surgery if

evidence of existing sludge or stones Prevent post-operative disease with concurrent bariatric

surgery and cholecystectomy Prophylactic use of urosidol

Expensive and unpalatable

Stomal Ulceration

12-15 within 2-4 mos Post-surgery Etiology

Overabundant acid in pouch leads to excessive acid passing through stoma

Pouch tension and staple line breakdown NSAID use

Presentation Dyspepsia vomiting Epigastric or retrosternal pain

Stomal Ulceration

Treatment PPI carafate Antibiotics if H Pylori Avoid NSAIDS alcohol smoking

If no response to treatment Endoscopy Back to surgery for pouch revision or staple line repair

Dumping Syndrome

More than 15 patients Hypotention Tachycardia Lightheadedness syncope Flushing Abdominal cramping and diarrhea Nausea and vomiting

Dumping Syndrome

Occurs with high dose simple sugar ingestion Sugar in small intestine causes osmotic overload and fluid

shift from blood to intestine Increased intestinal volume leads to watery diarrhea Decreased blood volume leads to systemic changes Patient education

Eat slowly Avoid drinking before during and not until 30 minutes after meals

Constipation

Most common complaint Causes

Dehydration and decreased fluid intake post-operatively Increased metabolic water needs Calcium and iron supplement use following surgery

Treat with increased fluids and stool softeners

Nutritional Consequences

Iron deficiency anemia B12 deficiency Folate deficiency Calcium and Vitamin D deficiency

Not seen with purely restrictive surgeries

Iron deficiency and anemia

Common following RYGB As high as 49 of patients Multifactorial cause

Low gastric acid levels prohibit iron cleavage from food Absorption inhibited because no nutrient exposure to duodenum or

proximal jejunum Decrease in iron-rich food consumption due to intolerance

Treat with oral supplementation of ferrous sulfate or ferrous gluconate

Vitamin B12 deficiency

Up to 70 of patients Lack of hydrochloric acid and pepsin in stomach

Prevents B12 cleavage from food Affects secretion of intrinsic factor thus B12 absorption

Intolerance to meat and milk Oral supplementation usually adequate otherwise IM injections used

Folate Deficiency

40 of gastric bypass patients Complete absorption requires B12 Absorption dependent on HCl and upper 13 stomach Deficiency generally caused by decreased consumption Oral supplementation

Vitamin D and Calcium Deficiency

Vitamin D deficiency is common among obese people Calcium absorption decreased because duodenum is

bypassed Intolerance to dairy foods high in calcium Vitamin D is required for Ca++ absorption Prolonged deficiencies lead to

Bone resorption osteomalacia osteoporosis Treat with calcium citrate supplementation and 2 weekly

doses of Vitamin D

Nutritional Implications of Various Bariatric Surgeries(34)

bull RYGB Malabsorption of Vit B12 Vit B1 (thiamin) Vit D Vit K Folate Iron Calcium

bull LAGB Folic Acid deficiency

bull BPD and BPDDS Vit A D E and K deficiency Protein-Calorie Malnutrition Malabsorption of

Calcium Zinc Selenium Sodium Potassium Chloride Phosphorus Magnesium

Recommended Daily Supplements(4)

Multivitamin with iron (prenatal vitamin will have adeq amount of folic acid)

Calcium (citrate) with vitamin D (1200-1500 mg calcium with 800-1000 IU vitamin D)

Oral vitamin B12 (500-1000 mcg) Iron (65 mgday in elemental form)

Vitamin C (to increase absorption of Iron) Thiamin (10 mgday)

Diet Recommendations(3)

Reduce food volume Chew food very well Slow pace of eating No liquids with meals Encourage fruits and vegetables as diet progresses Include high protein foods (at least 60gday) may need protein

supplements

Diet Progression Gastric Bypass

Stage 1 Clear liquids and protein supplement (1 week)

Stage 2No concentrated sweets low fat puree diet ( 3 weeks)

Stage 3 Regular texture weight reduction diet

Diet Progression Lap - Band

Stage 1 Clear liquids and protein supplement ( 2 weeks)

Stage 2 No concentrated sweets low fat puree diet (2weeks)

Stage 3 Regular texture weight reduction diet

Stage 1

Only clear liquids allowed Avoid sweetened beverages Sip very slowly No straws Avoid caffeinated carbonated and alcoholic beverages STOP drinking if you feel fullness pain or discomfort

Protein supplements

Begin the day after you go home from Hospital

Minimum protein target 70gmsday

May use powder or pre-mixed liquid forms (Whey protein is preferred)

Protein pills may not be used

Vitamin and Mineral Supplements

Gastric bypass patients In addition to eating much less food gastric bypass patients will also

absorb vitamins and minerals differently after surgery They will require daily multivitamin calcium and iron

supplementation for the rest of your life

Vitamin and Mineral Supplements

Lap-Bandreg patients

Require a multivitamin with minerals daily

It may be necessary to take additional vitamins and minerals eg calcium iron folateB1 B12These will be prescribed as needed

Stage 2 dietPUREE

Puree diet

Regular scheduled meals Avoid meal skipping Plan meals in advance Eat Slowly Eat protein foods first Moisten meats Use liquid protein as supplement not as meal replacement

Measure 2 oz portions at each meal eating when full Separate liquids and solids No bread rice or pasta Avoid added sugars and high fat

foods VARIETY

SLEEVE GASTRECTOMY

A sleeve gastrectomy involves resection of

approximately 80 of the greater curvature

side of the stomach

Smaller tubular gastric ldquosleeverdquo created

along the lesser curve that is based on the

lesser curvature blood supply

Ideal approximate capacity of the stomach

after the procedure is about 30- 60 ml pouch

1MECHANICAL RESTRICTION by reducing the volume of the stomach and impairing stomach mobility Also called lsquoFood limitingrsquo operation

2HORMONAL MODIFICATION by removing a great part of the Ghrelin (Hunger Hormone) production tissue

(Ghrelin is a 28 amino-acid-peptide secreted by the oxyntic glands of the gastric fungus It is a potent orexigenic (appetite-stimulating) peptide mediated by the activation of its receptors in the hypothalamus or pituitary area)

The gastric fundus contains 10 to 20 times more ghrelin per one gram of tissue than the duodenum In the SG resection of the fundus removes the major portion of ghrelin release therefore appetite decreases

The sleeve gastrectomy (SG) induces weight loss by 2 mechanisms

>

Intragastric balloon involves placing a deflated balloon into the stomach and then filling it to decrease the amount of gastric space

The balloon can be left in the stomach for a maximum of 6 months and results in an average weight loss of 5ndash9 BMI over half a year

Done endoscopically

The intragastric balloon may be used prior to another bariatric surgery as a step-down procedure

INTRA GASTRIC BALLOON

>

>

The EndoBarrier gastrointestinal liner mimics the effects of gastric bypass surgery

Itrsquos designed to work by inserting a flexible

tube-like barrier into the duodenum amp 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

ENDO BARRIER LINER SYSTEM

B MAL- ABSORPTIVE PROCEDURES

Malabsorptive surgeries rearrange andor remove part of digestive system which then limits the amount of calories and nutrients that body can absorb Treatment with a large malabsorptive component results in the most weight loss but tend to have slightly higher complication rates

1JEJUNAL ILEAL BYPASS ndash no longer performed for high complication rates

2ILEAL TRANSPOSITION- New malabsoptive procedure on trial for treatment of DM type 2 and metabolic disorders

C COMBINATION PROCEDURES RESTRICTIVE + MALABSORBTIVE

1LAP GASTRIC BYPASS ndash ROUX-EN- Y ndash more malabsorption than the restrictive

2MINI- GASTRIC BYPASS- mainly restrictive

3DUODENAL SWITCH ndash the sleeve stomach is the restrictive portion ampthe intestinal bypass (duodenal switch) is the malabsorptive component

When surgery combines both restrictive and malabsorptive techniques it is know as a ldquocombinationrdquo procedure Most types of bariatric surgery carry at least a small element of both components but the following surgeries achieve a notable portion of weight loss from eachhellip

1 LAP GASTRIC BYPASS LGB

The Roux-en-Y gastric bypass(known simply as the LRYGBP) is the most commonly performed procedure

It primarily causesweight loss by restricting thefood intake however there ismore amount of mal absorption that occurs with this operation

GASTRIC BYPASS LRYGBP

bullThe stomach is stapled into2 pieces one small and one large The small piece becomes the ldquonewrdquo stomach pouch

bull The larger portion of the stomach stays in place however will lie dormant for the remainder of the patientrsquos life

GASTRIC BYPASS LGB

bull The small intestine (the jejunum) is divided using a surgical staplerApprox 50-70 cm from the DJ Junction

GASTRIC BYPASS LGB

Y- LIMB BP LIMB

bull The end of the Roux limb is then attached to the newly formed stomach pouch which carries food to the distal intestine

bull The Roux loop is completed by forming a jejunostomy

bull The Y limb or BPD limb carries digestive juices from the pancreas gall bladder liver and duodenum to the intestines

bull The food and the digestive juices mix where the Roux limb and Y limb meet much below say 100-150 cm from DJ

Roux limb or alimentary limb

100-150 cm

How Does the Roux-en-Y Work

Surgery factors restriction of meal size ldquodumping syndromerdquo some malabsorption decreased appetite

Patient factors calorie intake calorie expenditure

bull Most commonly performedbull Most reliable operation for long term weight lossbull Long term weight loss averages 60 to 75 percent of EBWbull Malnutrition is unusualbull Substantial improvement amp resolution in many co-morbid

obesity conditions

ADVANTAGES OF RYGBP

1 Not reversible

2 Mortality 05- 1

3 Perioperative complications 5-10

4 Stricture of gastrojejunostomy-10 (long term)

5 Long term risk of protein amp vitamin deficiency and marginal ulceration of GJA

6Long term risk of intestinal obstruction ndash 2

LAPAROSCOPIC GASTRIC BYPASSCOMPLICATIONS

Biliopancreatic Diversion (BPD)

Primarily malabsorptive but restrictive component also

First Terminal ileum is measured to a length of 50 cms marked with suture

The alimentary tract beyond the proximal part of stomach is rearranged to

include only distal 200 cm of ileum including common channel

Common channel-Distal 50 cm of terminal ileum for absorption of fat and

protein

The proximal end of ileum anastomosed to proximal end of stomach after

performing distal hemigastrectomy

Biliopancreatic Diversion with Duodenal Switch

Modification to lessen high incidence of vit b12 deficiency anastomotic stricture at gastrojejunal anastomosis

This procedure involves a sleeve gastrectomy that is then diverted at the duodenum into the ileum at a point measured proximally from the ileocecal valve (usually 250 cm)

The distal duodenum and jejunum the biliopancreatic limb are then anastomosed to the ileum at a point measured proximally from the ileocecal valve (usually 100 cm)

Common channel is 100cm Entire alimentary tract is 250 cm This is the most aggressive bypass procedure commonly offered today Major difference-Sleeve gastrectomy instead of distal hemigastrectomy

bull Most women regained normal menstrual function and most had documented

spontaneous ovulation

bull Significant improvement in hirsutism androgen profiles and about a 50 reduction in

HOMA-IR

bull Follow up for more than 2 years showed that all women resumed normal menstrual

cycles HbA1C decreased from 82 to 51 in lt 3 months

bull 78 saw improvement in metabolic syndrome amp 48 showed improvement in PCOS

2 ROLE OF BARIATRIC SURGERY IN PCOS PATIENTS

bull Decrease menstrual irregularities bull PCOS women have less hyper androgenism

bull Sex hormone binding globulin increases bull LH and FSH levels have been reported to increase

bull Ovulatory function measured by luteal LH and Progesterone secretion improved bull Leptin levels decrease reflecting improved reproductive metabolic status

bull Subclinical hypothyroidism significantly reduced

THE SAFE TIMING OF PREGNANCYoptimal or minimal time gt12 months after bariatric surgery before becoming pregnant in order to allow the rapid weight loss and metabolic changes to subside

4 BARIATRIC SURGERY IN REPRODUCTIVE WOMEN

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)

The foregut hypothesis theory ndash 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

Effect of Bariatric Surgery on Diabetes Mellitus

Combined Gastric Restriction amp Malabsorption

Operative Risks (vs cholecystectomy)

Perioperative Mortality 1-2 vs 02-08 Early Complications 10 vs 29Late Complications 20 vs 1-2

LimitationsWidening of (unbanded) gastrojejunostomyExpansion of gastric pouch 25 with nearly 100 weight regainAdaptation of limb that receives the food

SUMMARY OF ALL TYPES OF SURGERY

bull LRYGBP ndash worlds best procedure 60-70 WL dumping syndrome malnutrition

bull LAGB- low complications varying range of wt loss frequent post-op visits ( 10)

bull DSBPD- more wt loss high complications good for high BMI gt 50 malabsorption +

bull VBG(vertical band gastroplasty) ndash longest available results good wt loss improved co-morbidities right for some ptsrisks too high to justify rewards

bull SG- needs long term research 1st step procedure low risks higher wt loss lesser complications pouch could Stretch over time long staple line could cause problems in future frequency is accelerating because of technical ease 1st stage procedure before bypass

Post-surgical Complications

Anastomosis leaks or staple line leaks Pulmonary Embolism or DVT Cholelithiasis Stomal ulceration Dumping syndrome Constipation

Anastamosis Leaks

Up to 7-10 days after surgery Most common at gastrojejunostomy enteroenterostomy Roux

limb stump staple line Can lead to peritonitis sepsis possible death Presentation

Tachycardia tachypnea Fever Ab painback pain Pelvic pressure or rebound tenderness

Anastamosis Leaks

Order Gastrograffin upper GI series Subclinical cases

Bowel rest Parenteral nutrition IV antibiotic if H pylori

Clinically suspect leak Laparoscopic evaluation and leak repair

Failure to evaluate is the most common cause of preventable major long-term disability or death in bariatric surgical patients

Pulmonary Embolism

Sudden cause of death up to one month after surgery 20-30 mortality rate High risk may have vena cava filter placement prior to surgery Prophylaxis with compression stockings and LMWH Early ambulation imperitive

Pulmonary Embolism

Presentation Profound hypoxia Hypotension Signs of sepsis

Immediate spiral chest CT Abdominal exploration if too large for machine No pathology start anticoagulation Too largehelliphellipNO SURGERY

Cholelithiasis

Up to 36 of patients within 6 months post-op Bile stasis leads to increased sludge and gallstones Prophylactic cholecystectomy prior to surgery if

evidence of existing sludge or stones Prevent post-operative disease with concurrent bariatric

surgery and cholecystectomy Prophylactic use of urosidol

Expensive and unpalatable

Stomal Ulceration

12-15 within 2-4 mos Post-surgery Etiology

Overabundant acid in pouch leads to excessive acid passing through stoma

Pouch tension and staple line breakdown NSAID use

Presentation Dyspepsia vomiting Epigastric or retrosternal pain

Stomal Ulceration

Treatment PPI carafate Antibiotics if H Pylori Avoid NSAIDS alcohol smoking

If no response to treatment Endoscopy Back to surgery for pouch revision or staple line repair

Dumping Syndrome

More than 15 patients Hypotention Tachycardia Lightheadedness syncope Flushing Abdominal cramping and diarrhea Nausea and vomiting

Dumping Syndrome

Occurs with high dose simple sugar ingestion Sugar in small intestine causes osmotic overload and fluid

shift from blood to intestine Increased intestinal volume leads to watery diarrhea Decreased blood volume leads to systemic changes Patient education

Eat slowly Avoid drinking before during and not until 30 minutes after meals

Constipation

Most common complaint Causes

Dehydration and decreased fluid intake post-operatively Increased metabolic water needs Calcium and iron supplement use following surgery

Treat with increased fluids and stool softeners

Nutritional Consequences

Iron deficiency anemia B12 deficiency Folate deficiency Calcium and Vitamin D deficiency

Not seen with purely restrictive surgeries

Iron deficiency and anemia

Common following RYGB As high as 49 of patients Multifactorial cause

Low gastric acid levels prohibit iron cleavage from food Absorption inhibited because no nutrient exposure to duodenum or

proximal jejunum Decrease in iron-rich food consumption due to intolerance

Treat with oral supplementation of ferrous sulfate or ferrous gluconate

Vitamin B12 deficiency

Up to 70 of patients Lack of hydrochloric acid and pepsin in stomach

Prevents B12 cleavage from food Affects secretion of intrinsic factor thus B12 absorption

Intolerance to meat and milk Oral supplementation usually adequate otherwise IM injections used

Folate Deficiency

40 of gastric bypass patients Complete absorption requires B12 Absorption dependent on HCl and upper 13 stomach Deficiency generally caused by decreased consumption Oral supplementation

Vitamin D and Calcium Deficiency

Vitamin D deficiency is common among obese people Calcium absorption decreased because duodenum is

bypassed Intolerance to dairy foods high in calcium Vitamin D is required for Ca++ absorption Prolonged deficiencies lead to

Bone resorption osteomalacia osteoporosis Treat with calcium citrate supplementation and 2 weekly

doses of Vitamin D

Nutritional Implications of Various Bariatric Surgeries(34)

bull RYGB Malabsorption of Vit B12 Vit B1 (thiamin) Vit D Vit K Folate Iron Calcium

bull LAGB Folic Acid deficiency

bull BPD and BPDDS Vit A D E and K deficiency Protein-Calorie Malnutrition Malabsorption of

Calcium Zinc Selenium Sodium Potassium Chloride Phosphorus Magnesium

Recommended Daily Supplements(4)

Multivitamin with iron (prenatal vitamin will have adeq amount of folic acid)

Calcium (citrate) with vitamin D (1200-1500 mg calcium with 800-1000 IU vitamin D)

Oral vitamin B12 (500-1000 mcg) Iron (65 mgday in elemental form)

Vitamin C (to increase absorption of Iron) Thiamin (10 mgday)

Diet Recommendations(3)

Reduce food volume Chew food very well Slow pace of eating No liquids with meals Encourage fruits and vegetables as diet progresses Include high protein foods (at least 60gday) may need protein

supplements

Diet Progression Gastric Bypass

Stage 1 Clear liquids and protein supplement (1 week)

Stage 2No concentrated sweets low fat puree diet ( 3 weeks)

Stage 3 Regular texture weight reduction diet

Diet Progression Lap - Band

Stage 1 Clear liquids and protein supplement ( 2 weeks)

Stage 2 No concentrated sweets low fat puree diet (2weeks)

Stage 3 Regular texture weight reduction diet

Stage 1

Only clear liquids allowed Avoid sweetened beverages Sip very slowly No straws Avoid caffeinated carbonated and alcoholic beverages STOP drinking if you feel fullness pain or discomfort

Protein supplements

Begin the day after you go home from Hospital

Minimum protein target 70gmsday

May use powder or pre-mixed liquid forms (Whey protein is preferred)

Protein pills may not be used

Vitamin and Mineral Supplements

Gastric bypass patients In addition to eating much less food gastric bypass patients will also

absorb vitamins and minerals differently after surgery They will require daily multivitamin calcium and iron

supplementation for the rest of your life

Vitamin and Mineral Supplements

Lap-Bandreg patients

Require a multivitamin with minerals daily

It may be necessary to take additional vitamins and minerals eg calcium iron folateB1 B12These will be prescribed as needed

Stage 2 dietPUREE

Puree diet

Regular scheduled meals Avoid meal skipping Plan meals in advance Eat Slowly Eat protein foods first Moisten meats Use liquid protein as supplement not as meal replacement

Measure 2 oz portions at each meal eating when full Separate liquids and solids No bread rice or pasta Avoid added sugars and high fat

foods VARIETY

1MECHANICAL RESTRICTION by reducing the volume of the stomach and impairing stomach mobility Also called lsquoFood limitingrsquo operation

2HORMONAL MODIFICATION by removing a great part of the Ghrelin (Hunger Hormone) production tissue

(Ghrelin is a 28 amino-acid-peptide secreted by the oxyntic glands of the gastric fungus It is a potent orexigenic (appetite-stimulating) peptide mediated by the activation of its receptors in the hypothalamus or pituitary area)

The gastric fundus contains 10 to 20 times more ghrelin per one gram of tissue than the duodenum In the SG resection of the fundus removes the major portion of ghrelin release therefore appetite decreases

The sleeve gastrectomy (SG) induces weight loss by 2 mechanisms

>

Intragastric balloon involves placing a deflated balloon into the stomach and then filling it to decrease the amount of gastric space

The balloon can be left in the stomach for a maximum of 6 months and results in an average weight loss of 5ndash9 BMI over half a year

Done endoscopically

The intragastric balloon may be used prior to another bariatric surgery as a step-down procedure

INTRA GASTRIC BALLOON

>

>

The EndoBarrier gastrointestinal liner mimics the effects of gastric bypass surgery

Itrsquos designed to work by inserting a flexible

tube-like barrier into the duodenum amp 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

ENDO BARRIER LINER SYSTEM

B MAL- ABSORPTIVE PROCEDURES

Malabsorptive surgeries rearrange andor remove part of digestive system which then limits the amount of calories and nutrients that body can absorb Treatment with a large malabsorptive component results in the most weight loss but tend to have slightly higher complication rates

1JEJUNAL ILEAL BYPASS ndash no longer performed for high complication rates

2ILEAL TRANSPOSITION- New malabsoptive procedure on trial for treatment of DM type 2 and metabolic disorders

C COMBINATION PROCEDURES RESTRICTIVE + MALABSORBTIVE

1LAP GASTRIC BYPASS ndash ROUX-EN- Y ndash more malabsorption than the restrictive

2MINI- GASTRIC BYPASS- mainly restrictive

3DUODENAL SWITCH ndash the sleeve stomach is the restrictive portion ampthe intestinal bypass (duodenal switch) is the malabsorptive component

When surgery combines both restrictive and malabsorptive techniques it is know as a ldquocombinationrdquo procedure Most types of bariatric surgery carry at least a small element of both components but the following surgeries achieve a notable portion of weight loss from eachhellip

1 LAP GASTRIC BYPASS LGB

The Roux-en-Y gastric bypass(known simply as the LRYGBP) is the most commonly performed procedure

It primarily causesweight loss by restricting thefood intake however there ismore amount of mal absorption that occurs with this operation

GASTRIC BYPASS LRYGBP

bullThe stomach is stapled into2 pieces one small and one large The small piece becomes the ldquonewrdquo stomach pouch

bull The larger portion of the stomach stays in place however will lie dormant for the remainder of the patientrsquos life

GASTRIC BYPASS LGB

bull The small intestine (the jejunum) is divided using a surgical staplerApprox 50-70 cm from the DJ Junction

GASTRIC BYPASS LGB

Y- LIMB BP LIMB

bull The end of the Roux limb is then attached to the newly formed stomach pouch which carries food to the distal intestine

bull The Roux loop is completed by forming a jejunostomy

bull The Y limb or BPD limb carries digestive juices from the pancreas gall bladder liver and duodenum to the intestines

bull The food and the digestive juices mix where the Roux limb and Y limb meet much below say 100-150 cm from DJ

Roux limb or alimentary limb

100-150 cm

How Does the Roux-en-Y Work

Surgery factors restriction of meal size ldquodumping syndromerdquo some malabsorption decreased appetite

Patient factors calorie intake calorie expenditure

bull Most commonly performedbull Most reliable operation for long term weight lossbull Long term weight loss averages 60 to 75 percent of EBWbull Malnutrition is unusualbull Substantial improvement amp resolution in many co-morbid

obesity conditions

ADVANTAGES OF RYGBP

1 Not reversible

2 Mortality 05- 1

3 Perioperative complications 5-10

4 Stricture of gastrojejunostomy-10 (long term)

5 Long term risk of protein amp vitamin deficiency and marginal ulceration of GJA

6Long term risk of intestinal obstruction ndash 2

LAPAROSCOPIC GASTRIC BYPASSCOMPLICATIONS

Biliopancreatic Diversion (BPD)

Primarily malabsorptive but restrictive component also

First Terminal ileum is measured to a length of 50 cms marked with suture

The alimentary tract beyond the proximal part of stomach is rearranged to

include only distal 200 cm of ileum including common channel

Common channel-Distal 50 cm of terminal ileum for absorption of fat and

protein

The proximal end of ileum anastomosed to proximal end of stomach after

performing distal hemigastrectomy

Biliopancreatic Diversion with Duodenal Switch

Modification to lessen high incidence of vit b12 deficiency anastomotic stricture at gastrojejunal anastomosis

This procedure involves a sleeve gastrectomy that is then diverted at the duodenum into the ileum at a point measured proximally from the ileocecal valve (usually 250 cm)

The distal duodenum and jejunum the biliopancreatic limb are then anastomosed to the ileum at a point measured proximally from the ileocecal valve (usually 100 cm)

Common channel is 100cm Entire alimentary tract is 250 cm This is the most aggressive bypass procedure commonly offered today Major difference-Sleeve gastrectomy instead of distal hemigastrectomy

bull Most women regained normal menstrual function and most had documented

spontaneous ovulation

bull Significant improvement in hirsutism androgen profiles and about a 50 reduction in

HOMA-IR

bull Follow up for more than 2 years showed that all women resumed normal menstrual

cycles HbA1C decreased from 82 to 51 in lt 3 months

bull 78 saw improvement in metabolic syndrome amp 48 showed improvement in PCOS

2 ROLE OF BARIATRIC SURGERY IN PCOS PATIENTS

bull Decrease menstrual irregularities bull PCOS women have less hyper androgenism

bull Sex hormone binding globulin increases bull LH and FSH levels have been reported to increase

bull Ovulatory function measured by luteal LH and Progesterone secretion improved bull Leptin levels decrease reflecting improved reproductive metabolic status

bull Subclinical hypothyroidism significantly reduced

THE SAFE TIMING OF PREGNANCYoptimal or minimal time gt12 months after bariatric surgery before becoming pregnant in order to allow the rapid weight loss and metabolic changes to subside

4 BARIATRIC SURGERY IN REPRODUCTIVE WOMEN

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)

The foregut hypothesis theory ndash 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

Effect of Bariatric Surgery on Diabetes Mellitus

Combined Gastric Restriction amp Malabsorption

Operative Risks (vs cholecystectomy)

Perioperative Mortality 1-2 vs 02-08 Early Complications 10 vs 29Late Complications 20 vs 1-2

LimitationsWidening of (unbanded) gastrojejunostomyExpansion of gastric pouch 25 with nearly 100 weight regainAdaptation of limb that receives the food

SUMMARY OF ALL TYPES OF SURGERY

bull LRYGBP ndash worlds best procedure 60-70 WL dumping syndrome malnutrition

bull LAGB- low complications varying range of wt loss frequent post-op visits ( 10)

bull DSBPD- more wt loss high complications good for high BMI gt 50 malabsorption +

bull VBG(vertical band gastroplasty) ndash longest available results good wt loss improved co-morbidities right for some ptsrisks too high to justify rewards

bull SG- needs long term research 1st step procedure low risks higher wt loss lesser complications pouch could Stretch over time long staple line could cause problems in future frequency is accelerating because of technical ease 1st stage procedure before bypass

Post-surgical Complications

Anastomosis leaks or staple line leaks Pulmonary Embolism or DVT Cholelithiasis Stomal ulceration Dumping syndrome Constipation

Anastamosis Leaks

Up to 7-10 days after surgery Most common at gastrojejunostomy enteroenterostomy Roux

limb stump staple line Can lead to peritonitis sepsis possible death Presentation

Tachycardia tachypnea Fever Ab painback pain Pelvic pressure or rebound tenderness

Anastamosis Leaks

Order Gastrograffin upper GI series Subclinical cases

Bowel rest Parenteral nutrition IV antibiotic if H pylori

Clinically suspect leak Laparoscopic evaluation and leak repair

Failure to evaluate is the most common cause of preventable major long-term disability or death in bariatric surgical patients

Pulmonary Embolism

Sudden cause of death up to one month after surgery 20-30 mortality rate High risk may have vena cava filter placement prior to surgery Prophylaxis with compression stockings and LMWH Early ambulation imperitive

Pulmonary Embolism

Presentation Profound hypoxia Hypotension Signs of sepsis

Immediate spiral chest CT Abdominal exploration if too large for machine No pathology start anticoagulation Too largehelliphellipNO SURGERY

Cholelithiasis

Up to 36 of patients within 6 months post-op Bile stasis leads to increased sludge and gallstones Prophylactic cholecystectomy prior to surgery if

evidence of existing sludge or stones Prevent post-operative disease with concurrent bariatric

surgery and cholecystectomy Prophylactic use of urosidol

Expensive and unpalatable

Stomal Ulceration

12-15 within 2-4 mos Post-surgery Etiology

Overabundant acid in pouch leads to excessive acid passing through stoma

Pouch tension and staple line breakdown NSAID use

Presentation Dyspepsia vomiting Epigastric or retrosternal pain

Stomal Ulceration

Treatment PPI carafate Antibiotics if H Pylori Avoid NSAIDS alcohol smoking

If no response to treatment Endoscopy Back to surgery for pouch revision or staple line repair

Dumping Syndrome

More than 15 patients Hypotention Tachycardia Lightheadedness syncope Flushing Abdominal cramping and diarrhea Nausea and vomiting

Dumping Syndrome

Occurs with high dose simple sugar ingestion Sugar in small intestine causes osmotic overload and fluid

shift from blood to intestine Increased intestinal volume leads to watery diarrhea Decreased blood volume leads to systemic changes Patient education

Eat slowly Avoid drinking before during and not until 30 minutes after meals

Constipation

Most common complaint Causes

Dehydration and decreased fluid intake post-operatively Increased metabolic water needs Calcium and iron supplement use following surgery

Treat with increased fluids and stool softeners

Nutritional Consequences

Iron deficiency anemia B12 deficiency Folate deficiency Calcium and Vitamin D deficiency

Not seen with purely restrictive surgeries

Iron deficiency and anemia

Common following RYGB As high as 49 of patients Multifactorial cause

Low gastric acid levels prohibit iron cleavage from food Absorption inhibited because no nutrient exposure to duodenum or

proximal jejunum Decrease in iron-rich food consumption due to intolerance

Treat with oral supplementation of ferrous sulfate or ferrous gluconate

Vitamin B12 deficiency

Up to 70 of patients Lack of hydrochloric acid and pepsin in stomach

Prevents B12 cleavage from food Affects secretion of intrinsic factor thus B12 absorption

Intolerance to meat and milk Oral supplementation usually adequate otherwise IM injections used

Folate Deficiency

40 of gastric bypass patients Complete absorption requires B12 Absorption dependent on HCl and upper 13 stomach Deficiency generally caused by decreased consumption Oral supplementation

Vitamin D and Calcium Deficiency

Vitamin D deficiency is common among obese people Calcium absorption decreased because duodenum is

bypassed Intolerance to dairy foods high in calcium Vitamin D is required for Ca++ absorption Prolonged deficiencies lead to

Bone resorption osteomalacia osteoporosis Treat with calcium citrate supplementation and 2 weekly

doses of Vitamin D

Nutritional Implications of Various Bariatric Surgeries(34)

bull RYGB Malabsorption of Vit B12 Vit B1 (thiamin) Vit D Vit K Folate Iron Calcium

bull LAGB Folic Acid deficiency

bull BPD and BPDDS Vit A D E and K deficiency Protein-Calorie Malnutrition Malabsorption of

Calcium Zinc Selenium Sodium Potassium Chloride Phosphorus Magnesium

Recommended Daily Supplements(4)

Multivitamin with iron (prenatal vitamin will have adeq amount of folic acid)

Calcium (citrate) with vitamin D (1200-1500 mg calcium with 800-1000 IU vitamin D)

Oral vitamin B12 (500-1000 mcg) Iron (65 mgday in elemental form)

Vitamin C (to increase absorption of Iron) Thiamin (10 mgday)

Diet Recommendations(3)

Reduce food volume Chew food very well Slow pace of eating No liquids with meals Encourage fruits and vegetables as diet progresses Include high protein foods (at least 60gday) may need protein

supplements

Diet Progression Gastric Bypass

Stage 1 Clear liquids and protein supplement (1 week)

Stage 2No concentrated sweets low fat puree diet ( 3 weeks)

Stage 3 Regular texture weight reduction diet

Diet Progression Lap - Band

Stage 1 Clear liquids and protein supplement ( 2 weeks)

Stage 2 No concentrated sweets low fat puree diet (2weeks)

Stage 3 Regular texture weight reduction diet

Stage 1

Only clear liquids allowed Avoid sweetened beverages Sip very slowly No straws Avoid caffeinated carbonated and alcoholic beverages STOP drinking if you feel fullness pain or discomfort

Protein supplements

Begin the day after you go home from Hospital

Minimum protein target 70gmsday

May use powder or pre-mixed liquid forms (Whey protein is preferred)

Protein pills may not be used

Vitamin and Mineral Supplements

Gastric bypass patients In addition to eating much less food gastric bypass patients will also

absorb vitamins and minerals differently after surgery They will require daily multivitamin calcium and iron

supplementation for the rest of your life

Vitamin and Mineral Supplements

Lap-Bandreg patients

Require a multivitamin with minerals daily

It may be necessary to take additional vitamins and minerals eg calcium iron folateB1 B12These will be prescribed as needed

Stage 2 dietPUREE

Puree diet

Regular scheduled meals Avoid meal skipping Plan meals in advance Eat Slowly Eat protein foods first Moisten meats Use liquid protein as supplement not as meal replacement

Measure 2 oz portions at each meal eating when full Separate liquids and solids No bread rice or pasta Avoid added sugars and high fat

foods VARIETY

>

Intragastric balloon involves placing a deflated balloon into the stomach and then filling it to decrease the amount of gastric space

The balloon can be left in the stomach for a maximum of 6 months and results in an average weight loss of 5ndash9 BMI over half a year

Done endoscopically

The intragastric balloon may be used prior to another bariatric surgery as a step-down procedure

INTRA GASTRIC BALLOON

>

>

The EndoBarrier gastrointestinal liner mimics the effects of gastric bypass surgery

Itrsquos designed to work by inserting a flexible

tube-like barrier into the duodenum amp 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

ENDO BARRIER LINER SYSTEM

B MAL- ABSORPTIVE PROCEDURES

Malabsorptive surgeries rearrange andor remove part of digestive system which then limits the amount of calories and nutrients that body can absorb Treatment with a large malabsorptive component results in the most weight loss but tend to have slightly higher complication rates

1JEJUNAL ILEAL BYPASS ndash no longer performed for high complication rates

2ILEAL TRANSPOSITION- New malabsoptive procedure on trial for treatment of DM type 2 and metabolic disorders

C COMBINATION PROCEDURES RESTRICTIVE + MALABSORBTIVE

1LAP GASTRIC BYPASS ndash ROUX-EN- Y ndash more malabsorption than the restrictive

2MINI- GASTRIC BYPASS- mainly restrictive

3DUODENAL SWITCH ndash the sleeve stomach is the restrictive portion ampthe intestinal bypass (duodenal switch) is the malabsorptive component

When surgery combines both restrictive and malabsorptive techniques it is know as a ldquocombinationrdquo procedure Most types of bariatric surgery carry at least a small element of both components but the following surgeries achieve a notable portion of weight loss from eachhellip

1 LAP GASTRIC BYPASS LGB

The Roux-en-Y gastric bypass(known simply as the LRYGBP) is the most commonly performed procedure

It primarily causesweight loss by restricting thefood intake however there ismore amount of mal absorption that occurs with this operation

GASTRIC BYPASS LRYGBP

bullThe stomach is stapled into2 pieces one small and one large The small piece becomes the ldquonewrdquo stomach pouch

bull The larger portion of the stomach stays in place however will lie dormant for the remainder of the patientrsquos life

GASTRIC BYPASS LGB

bull The small intestine (the jejunum) is divided using a surgical staplerApprox 50-70 cm from the DJ Junction

GASTRIC BYPASS LGB

Y- LIMB BP LIMB

bull The end of the Roux limb is then attached to the newly formed stomach pouch which carries food to the distal intestine

bull The Roux loop is completed by forming a jejunostomy

bull The Y limb or BPD limb carries digestive juices from the pancreas gall bladder liver and duodenum to the intestines

bull The food and the digestive juices mix where the Roux limb and Y limb meet much below say 100-150 cm from DJ

Roux limb or alimentary limb

100-150 cm

How Does the Roux-en-Y Work

Surgery factors restriction of meal size ldquodumping syndromerdquo some malabsorption decreased appetite

Patient factors calorie intake calorie expenditure

bull Most commonly performedbull Most reliable operation for long term weight lossbull Long term weight loss averages 60 to 75 percent of EBWbull Malnutrition is unusualbull Substantial improvement amp resolution in many co-morbid

obesity conditions

ADVANTAGES OF RYGBP

1 Not reversible

2 Mortality 05- 1

3 Perioperative complications 5-10

4 Stricture of gastrojejunostomy-10 (long term)

5 Long term risk of protein amp vitamin deficiency and marginal ulceration of GJA

6Long term risk of intestinal obstruction ndash 2

LAPAROSCOPIC GASTRIC BYPASSCOMPLICATIONS

Biliopancreatic Diversion (BPD)

Primarily malabsorptive but restrictive component also

First Terminal ileum is measured to a length of 50 cms marked with suture

The alimentary tract beyond the proximal part of stomach is rearranged to

include only distal 200 cm of ileum including common channel

Common channel-Distal 50 cm of terminal ileum for absorption of fat and

protein

The proximal end of ileum anastomosed to proximal end of stomach after

performing distal hemigastrectomy

Biliopancreatic Diversion with Duodenal Switch

Modification to lessen high incidence of vit b12 deficiency anastomotic stricture at gastrojejunal anastomosis

This procedure involves a sleeve gastrectomy that is then diverted at the duodenum into the ileum at a point measured proximally from the ileocecal valve (usually 250 cm)

The distal duodenum and jejunum the biliopancreatic limb are then anastomosed to the ileum at a point measured proximally from the ileocecal valve (usually 100 cm)

Common channel is 100cm Entire alimentary tract is 250 cm This is the most aggressive bypass procedure commonly offered today Major difference-Sleeve gastrectomy instead of distal hemigastrectomy

bull Most women regained normal menstrual function and most had documented

spontaneous ovulation

bull Significant improvement in hirsutism androgen profiles and about a 50 reduction in

HOMA-IR

bull Follow up for more than 2 years showed that all women resumed normal menstrual

cycles HbA1C decreased from 82 to 51 in lt 3 months

bull 78 saw improvement in metabolic syndrome amp 48 showed improvement in PCOS

2 ROLE OF BARIATRIC SURGERY IN PCOS PATIENTS

bull Decrease menstrual irregularities bull PCOS women have less hyper androgenism

bull Sex hormone binding globulin increases bull LH and FSH levels have been reported to increase

bull Ovulatory function measured by luteal LH and Progesterone secretion improved bull Leptin levels decrease reflecting improved reproductive metabolic status

bull Subclinical hypothyroidism significantly reduced

THE SAFE TIMING OF PREGNANCYoptimal or minimal time gt12 months after bariatric surgery before becoming pregnant in order to allow the rapid weight loss and metabolic changes to subside

4 BARIATRIC SURGERY IN REPRODUCTIVE WOMEN

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)

The foregut hypothesis theory ndash 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

Effect of Bariatric Surgery on Diabetes Mellitus

Combined Gastric Restriction amp Malabsorption

Operative Risks (vs cholecystectomy)

Perioperative Mortality 1-2 vs 02-08 Early Complications 10 vs 29Late Complications 20 vs 1-2

LimitationsWidening of (unbanded) gastrojejunostomyExpansion of gastric pouch 25 with nearly 100 weight regainAdaptation of limb that receives the food

SUMMARY OF ALL TYPES OF SURGERY

bull LRYGBP ndash worlds best procedure 60-70 WL dumping syndrome malnutrition

bull LAGB- low complications varying range of wt loss frequent post-op visits ( 10)

bull DSBPD- more wt loss high complications good for high BMI gt 50 malabsorption +

bull VBG(vertical band gastroplasty) ndash longest available results good wt loss improved co-morbidities right for some ptsrisks too high to justify rewards

bull SG- needs long term research 1st step procedure low risks higher wt loss lesser complications pouch could Stretch over time long staple line could cause problems in future frequency is accelerating because of technical ease 1st stage procedure before bypass

Post-surgical Complications

Anastomosis leaks or staple line leaks Pulmonary Embolism or DVT Cholelithiasis Stomal ulceration Dumping syndrome Constipation

Anastamosis Leaks

Up to 7-10 days after surgery Most common at gastrojejunostomy enteroenterostomy Roux

limb stump staple line Can lead to peritonitis sepsis possible death Presentation

Tachycardia tachypnea Fever Ab painback pain Pelvic pressure or rebound tenderness

Anastamosis Leaks

Order Gastrograffin upper GI series Subclinical cases

Bowel rest Parenteral nutrition IV antibiotic if H pylori

Clinically suspect leak Laparoscopic evaluation and leak repair

Failure to evaluate is the most common cause of preventable major long-term disability or death in bariatric surgical patients

Pulmonary Embolism

Sudden cause of death up to one month after surgery 20-30 mortality rate High risk may have vena cava filter placement prior to surgery Prophylaxis with compression stockings and LMWH Early ambulation imperitive

Pulmonary Embolism

Presentation Profound hypoxia Hypotension Signs of sepsis

Immediate spiral chest CT Abdominal exploration if too large for machine No pathology start anticoagulation Too largehelliphellipNO SURGERY

Cholelithiasis

Up to 36 of patients within 6 months post-op Bile stasis leads to increased sludge and gallstones Prophylactic cholecystectomy prior to surgery if

evidence of existing sludge or stones Prevent post-operative disease with concurrent bariatric

surgery and cholecystectomy Prophylactic use of urosidol

Expensive and unpalatable

Stomal Ulceration

12-15 within 2-4 mos Post-surgery Etiology

Overabundant acid in pouch leads to excessive acid passing through stoma

Pouch tension and staple line breakdown NSAID use

Presentation Dyspepsia vomiting Epigastric or retrosternal pain

Stomal Ulceration

Treatment PPI carafate Antibiotics if H Pylori Avoid NSAIDS alcohol smoking

If no response to treatment Endoscopy Back to surgery for pouch revision or staple line repair

Dumping Syndrome

More than 15 patients Hypotention Tachycardia Lightheadedness syncope Flushing Abdominal cramping and diarrhea Nausea and vomiting

Dumping Syndrome

Occurs with high dose simple sugar ingestion Sugar in small intestine causes osmotic overload and fluid

shift from blood to intestine Increased intestinal volume leads to watery diarrhea Decreased blood volume leads to systemic changes Patient education

Eat slowly Avoid drinking before during and not until 30 minutes after meals

Constipation

Most common complaint Causes

Dehydration and decreased fluid intake post-operatively Increased metabolic water needs Calcium and iron supplement use following surgery

Treat with increased fluids and stool softeners

Nutritional Consequences

Iron deficiency anemia B12 deficiency Folate deficiency Calcium and Vitamin D deficiency

Not seen with purely restrictive surgeries

Iron deficiency and anemia

Common following RYGB As high as 49 of patients Multifactorial cause

Low gastric acid levels prohibit iron cleavage from food Absorption inhibited because no nutrient exposure to duodenum or

proximal jejunum Decrease in iron-rich food consumption due to intolerance

Treat with oral supplementation of ferrous sulfate or ferrous gluconate

Vitamin B12 deficiency

Up to 70 of patients Lack of hydrochloric acid and pepsin in stomach

Prevents B12 cleavage from food Affects secretion of intrinsic factor thus B12 absorption

Intolerance to meat and milk Oral supplementation usually adequate otherwise IM injections used

Folate Deficiency

40 of gastric bypass patients Complete absorption requires B12 Absorption dependent on HCl and upper 13 stomach Deficiency generally caused by decreased consumption Oral supplementation

Vitamin D and Calcium Deficiency

Vitamin D deficiency is common among obese people Calcium absorption decreased because duodenum is

bypassed Intolerance to dairy foods high in calcium Vitamin D is required for Ca++ absorption Prolonged deficiencies lead to

Bone resorption osteomalacia osteoporosis Treat with calcium citrate supplementation and 2 weekly

doses of Vitamin D

Nutritional Implications of Various Bariatric Surgeries(34)

bull RYGB Malabsorption of Vit B12 Vit B1 (thiamin) Vit D Vit K Folate Iron Calcium

bull LAGB Folic Acid deficiency

bull BPD and BPDDS Vit A D E and K deficiency Protein-Calorie Malnutrition Malabsorption of

Calcium Zinc Selenium Sodium Potassium Chloride Phosphorus Magnesium

Recommended Daily Supplements(4)

Multivitamin with iron (prenatal vitamin will have adeq amount of folic acid)

Calcium (citrate) with vitamin D (1200-1500 mg calcium with 800-1000 IU vitamin D)

Oral vitamin B12 (500-1000 mcg) Iron (65 mgday in elemental form)

Vitamin C (to increase absorption of Iron) Thiamin (10 mgday)

Diet Recommendations(3)

Reduce food volume Chew food very well Slow pace of eating No liquids with meals Encourage fruits and vegetables as diet progresses Include high protein foods (at least 60gday) may need protein

supplements

Diet Progression Gastric Bypass

Stage 1 Clear liquids and protein supplement (1 week)

Stage 2No concentrated sweets low fat puree diet ( 3 weeks)

Stage 3 Regular texture weight reduction diet

Diet Progression Lap - Band

Stage 1 Clear liquids and protein supplement ( 2 weeks)

Stage 2 No concentrated sweets low fat puree diet (2weeks)

Stage 3 Regular texture weight reduction diet

Stage 1

Only clear liquids allowed Avoid sweetened beverages Sip very slowly No straws Avoid caffeinated carbonated and alcoholic beverages STOP drinking if you feel fullness pain or discomfort

Protein supplements

Begin the day after you go home from Hospital

Minimum protein target 70gmsday

May use powder or pre-mixed liquid forms (Whey protein is preferred)

Protein pills may not be used

Vitamin and Mineral Supplements

Gastric bypass patients In addition to eating much less food gastric bypass patients will also

absorb vitamins and minerals differently after surgery They will require daily multivitamin calcium and iron

supplementation for the rest of your life

Vitamin and Mineral Supplements

Lap-Bandreg patients

Require a multivitamin with minerals daily

It may be necessary to take additional vitamins and minerals eg calcium iron folateB1 B12These will be prescribed as needed

Stage 2 dietPUREE

Puree diet

Regular scheduled meals Avoid meal skipping Plan meals in advance Eat Slowly Eat protein foods first Moisten meats Use liquid protein as supplement not as meal replacement

Measure 2 oz portions at each meal eating when full Separate liquids and solids No bread rice or pasta Avoid added sugars and high fat

foods VARIETY

Intragastric balloon involves placing a deflated balloon into the stomach and then filling it to decrease the amount of gastric space

The balloon can be left in the stomach for a maximum of 6 months and results in an average weight loss of 5ndash9 BMI over half a year

Done endoscopically

The intragastric balloon may be used prior to another bariatric surgery as a step-down procedure

INTRA GASTRIC BALLOON

>

>

The EndoBarrier gastrointestinal liner mimics the effects of gastric bypass surgery

Itrsquos designed to work by inserting a flexible

tube-like barrier into the duodenum amp 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

ENDO BARRIER LINER SYSTEM

B MAL- ABSORPTIVE PROCEDURES

Malabsorptive surgeries rearrange andor remove part of digestive system which then limits the amount of calories and nutrients that body can absorb Treatment with a large malabsorptive component results in the most weight loss but tend to have slightly higher complication rates

1JEJUNAL ILEAL BYPASS ndash no longer performed for high complication rates

2ILEAL TRANSPOSITION- New malabsoptive procedure on trial for treatment of DM type 2 and metabolic disorders

C COMBINATION PROCEDURES RESTRICTIVE + MALABSORBTIVE

1LAP GASTRIC BYPASS ndash ROUX-EN- Y ndash more malabsorption than the restrictive

2MINI- GASTRIC BYPASS- mainly restrictive

3DUODENAL SWITCH ndash the sleeve stomach is the restrictive portion ampthe intestinal bypass (duodenal switch) is the malabsorptive component

When surgery combines both restrictive and malabsorptive techniques it is know as a ldquocombinationrdquo procedure Most types of bariatric surgery carry at least a small element of both components but the following surgeries achieve a notable portion of weight loss from eachhellip

1 LAP GASTRIC BYPASS LGB

The Roux-en-Y gastric bypass(known simply as the LRYGBP) is the most commonly performed procedure

It primarily causesweight loss by restricting thefood intake however there ismore amount of mal absorption that occurs with this operation

GASTRIC BYPASS LRYGBP

bullThe stomach is stapled into2 pieces one small and one large The small piece becomes the ldquonewrdquo stomach pouch

bull The larger portion of the stomach stays in place however will lie dormant for the remainder of the patientrsquos life

GASTRIC BYPASS LGB

bull The small intestine (the jejunum) is divided using a surgical staplerApprox 50-70 cm from the DJ Junction

GASTRIC BYPASS LGB

Y- LIMB BP LIMB

bull The end of the Roux limb is then attached to the newly formed stomach pouch which carries food to the distal intestine

bull The Roux loop is completed by forming a jejunostomy

bull The Y limb or BPD limb carries digestive juices from the pancreas gall bladder liver and duodenum to the intestines

bull The food and the digestive juices mix where the Roux limb and Y limb meet much below say 100-150 cm from DJ

Roux limb or alimentary limb

100-150 cm

How Does the Roux-en-Y Work

Surgery factors restriction of meal size ldquodumping syndromerdquo some malabsorption decreased appetite

Patient factors calorie intake calorie expenditure

bull Most commonly performedbull Most reliable operation for long term weight lossbull Long term weight loss averages 60 to 75 percent of EBWbull Malnutrition is unusualbull Substantial improvement amp resolution in many co-morbid

obesity conditions

ADVANTAGES OF RYGBP

1 Not reversible

2 Mortality 05- 1

3 Perioperative complications 5-10

4 Stricture of gastrojejunostomy-10 (long term)

5 Long term risk of protein amp vitamin deficiency and marginal ulceration of GJA

6Long term risk of intestinal obstruction ndash 2

LAPAROSCOPIC GASTRIC BYPASSCOMPLICATIONS

Biliopancreatic Diversion (BPD)

Primarily malabsorptive but restrictive component also

First Terminal ileum is measured to a length of 50 cms marked with suture

The alimentary tract beyond the proximal part of stomach is rearranged to

include only distal 200 cm of ileum including common channel

Common channel-Distal 50 cm of terminal ileum for absorption of fat and

protein

The proximal end of ileum anastomosed to proximal end of stomach after

performing distal hemigastrectomy

Biliopancreatic Diversion with Duodenal Switch

Modification to lessen high incidence of vit b12 deficiency anastomotic stricture at gastrojejunal anastomosis

This procedure involves a sleeve gastrectomy that is then diverted at the duodenum into the ileum at a point measured proximally from the ileocecal valve (usually 250 cm)

The distal duodenum and jejunum the biliopancreatic limb are then anastomosed to the ileum at a point measured proximally from the ileocecal valve (usually 100 cm)

Common channel is 100cm Entire alimentary tract is 250 cm This is the most aggressive bypass procedure commonly offered today Major difference-Sleeve gastrectomy instead of distal hemigastrectomy

bull Most women regained normal menstrual function and most had documented

spontaneous ovulation

bull Significant improvement in hirsutism androgen profiles and about a 50 reduction in

HOMA-IR

bull Follow up for more than 2 years showed that all women resumed normal menstrual

cycles HbA1C decreased from 82 to 51 in lt 3 months

bull 78 saw improvement in metabolic syndrome amp 48 showed improvement in PCOS

2 ROLE OF BARIATRIC SURGERY IN PCOS PATIENTS

bull Decrease menstrual irregularities bull PCOS women have less hyper androgenism

bull Sex hormone binding globulin increases bull LH and FSH levels have been reported to increase

bull Ovulatory function measured by luteal LH and Progesterone secretion improved bull Leptin levels decrease reflecting improved reproductive metabolic status

bull Subclinical hypothyroidism significantly reduced

THE SAFE TIMING OF PREGNANCYoptimal or minimal time gt12 months after bariatric surgery before becoming pregnant in order to allow the rapid weight loss and metabolic changes to subside

4 BARIATRIC SURGERY IN REPRODUCTIVE WOMEN

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)

The foregut hypothesis theory ndash 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

Effect of Bariatric Surgery on Diabetes Mellitus

Combined Gastric Restriction amp Malabsorption

Operative Risks (vs cholecystectomy)

Perioperative Mortality 1-2 vs 02-08 Early Complications 10 vs 29Late Complications 20 vs 1-2

LimitationsWidening of (unbanded) gastrojejunostomyExpansion of gastric pouch 25 with nearly 100 weight regainAdaptation of limb that receives the food

SUMMARY OF ALL TYPES OF SURGERY

bull LRYGBP ndash worlds best procedure 60-70 WL dumping syndrome malnutrition

bull LAGB- low complications varying range of wt loss frequent post-op visits ( 10)

bull DSBPD- more wt loss high complications good for high BMI gt 50 malabsorption +

bull VBG(vertical band gastroplasty) ndash longest available results good wt loss improved co-morbidities right for some ptsrisks too high to justify rewards

bull SG- needs long term research 1st step procedure low risks higher wt loss lesser complications pouch could Stretch over time long staple line could cause problems in future frequency is accelerating because of technical ease 1st stage procedure before bypass

Post-surgical Complications

Anastomosis leaks or staple line leaks Pulmonary Embolism or DVT Cholelithiasis Stomal ulceration Dumping syndrome Constipation

Anastamosis Leaks

Up to 7-10 days after surgery Most common at gastrojejunostomy enteroenterostomy Roux

limb stump staple line Can lead to peritonitis sepsis possible death Presentation

Tachycardia tachypnea Fever Ab painback pain Pelvic pressure or rebound tenderness

Anastamosis Leaks

Order Gastrograffin upper GI series Subclinical cases

Bowel rest Parenteral nutrition IV antibiotic if H pylori

Clinically suspect leak Laparoscopic evaluation and leak repair

Failure to evaluate is the most common cause of preventable major long-term disability or death in bariatric surgical patients

Pulmonary Embolism

Sudden cause of death up to one month after surgery 20-30 mortality rate High risk may have vena cava filter placement prior to surgery Prophylaxis with compression stockings and LMWH Early ambulation imperitive

Pulmonary Embolism

Presentation Profound hypoxia Hypotension Signs of sepsis

Immediate spiral chest CT Abdominal exploration if too large for machine No pathology start anticoagulation Too largehelliphellipNO SURGERY

Cholelithiasis

Up to 36 of patients within 6 months post-op Bile stasis leads to increased sludge and gallstones Prophylactic cholecystectomy prior to surgery if

evidence of existing sludge or stones Prevent post-operative disease with concurrent bariatric

surgery and cholecystectomy Prophylactic use of urosidol

Expensive and unpalatable

Stomal Ulceration

12-15 within 2-4 mos Post-surgery Etiology

Overabundant acid in pouch leads to excessive acid passing through stoma

Pouch tension and staple line breakdown NSAID use

Presentation Dyspepsia vomiting Epigastric or retrosternal pain

Stomal Ulceration

Treatment PPI carafate Antibiotics if H Pylori Avoid NSAIDS alcohol smoking

If no response to treatment Endoscopy Back to surgery for pouch revision or staple line repair

Dumping Syndrome

More than 15 patients Hypotention Tachycardia Lightheadedness syncope Flushing Abdominal cramping and diarrhea Nausea and vomiting

Dumping Syndrome

Occurs with high dose simple sugar ingestion Sugar in small intestine causes osmotic overload and fluid

shift from blood to intestine Increased intestinal volume leads to watery diarrhea Decreased blood volume leads to systemic changes Patient education

Eat slowly Avoid drinking before during and not until 30 minutes after meals

Constipation

Most common complaint Causes

Dehydration and decreased fluid intake post-operatively Increased metabolic water needs Calcium and iron supplement use following surgery

Treat with increased fluids and stool softeners

Nutritional Consequences

Iron deficiency anemia B12 deficiency Folate deficiency Calcium and Vitamin D deficiency

Not seen with purely restrictive surgeries

Iron deficiency and anemia

Common following RYGB As high as 49 of patients Multifactorial cause

Low gastric acid levels prohibit iron cleavage from food Absorption inhibited because no nutrient exposure to duodenum or

proximal jejunum Decrease in iron-rich food consumption due to intolerance

Treat with oral supplementation of ferrous sulfate or ferrous gluconate

Vitamin B12 deficiency

Up to 70 of patients Lack of hydrochloric acid and pepsin in stomach

Prevents B12 cleavage from food Affects secretion of intrinsic factor thus B12 absorption

Intolerance to meat and milk Oral supplementation usually adequate otherwise IM injections used

Folate Deficiency

40 of gastric bypass patients Complete absorption requires B12 Absorption dependent on HCl and upper 13 stomach Deficiency generally caused by decreased consumption Oral supplementation

Vitamin D and Calcium Deficiency

Vitamin D deficiency is common among obese people Calcium absorption decreased because duodenum is

bypassed Intolerance to dairy foods high in calcium Vitamin D is required for Ca++ absorption Prolonged deficiencies lead to

Bone resorption osteomalacia osteoporosis Treat with calcium citrate supplementation and 2 weekly

doses of Vitamin D

Nutritional Implications of Various Bariatric Surgeries(34)

bull RYGB Malabsorption of Vit B12 Vit B1 (thiamin) Vit D Vit K Folate Iron Calcium

bull LAGB Folic Acid deficiency

bull BPD and BPDDS Vit A D E and K deficiency Protein-Calorie Malnutrition Malabsorption of

Calcium Zinc Selenium Sodium Potassium Chloride Phosphorus Magnesium

Recommended Daily Supplements(4)

Multivitamin with iron (prenatal vitamin will have adeq amount of folic acid)

Calcium (citrate) with vitamin D (1200-1500 mg calcium with 800-1000 IU vitamin D)

Oral vitamin B12 (500-1000 mcg) Iron (65 mgday in elemental form)

Vitamin C (to increase absorption of Iron) Thiamin (10 mgday)

Diet Recommendations(3)

Reduce food volume Chew food very well Slow pace of eating No liquids with meals Encourage fruits and vegetables as diet progresses Include high protein foods (at least 60gday) may need protein

supplements

Diet Progression Gastric Bypass

Stage 1 Clear liquids and protein supplement (1 week)

Stage 2No concentrated sweets low fat puree diet ( 3 weeks)

Stage 3 Regular texture weight reduction diet

Diet Progression Lap - Band

Stage 1 Clear liquids and protein supplement ( 2 weeks)

Stage 2 No concentrated sweets low fat puree diet (2weeks)

Stage 3 Regular texture weight reduction diet

Stage 1

Only clear liquids allowed Avoid sweetened beverages Sip very slowly No straws Avoid caffeinated carbonated and alcoholic beverages STOP drinking if you feel fullness pain or discomfort

Protein supplements

Begin the day after you go home from Hospital

Minimum protein target 70gmsday

May use powder or pre-mixed liquid forms (Whey protein is preferred)

Protein pills may not be used

Vitamin and Mineral Supplements

Gastric bypass patients In addition to eating much less food gastric bypass patients will also

absorb vitamins and minerals differently after surgery They will require daily multivitamin calcium and iron

supplementation for the rest of your life

Vitamin and Mineral Supplements

Lap-Bandreg patients

Require a multivitamin with minerals daily

It may be necessary to take additional vitamins and minerals eg calcium iron folateB1 B12These will be prescribed as needed

Stage 2 dietPUREE

Puree diet

Regular scheduled meals Avoid meal skipping Plan meals in advance Eat Slowly Eat protein foods first Moisten meats Use liquid protein as supplement not as meal replacement

Measure 2 oz portions at each meal eating when full Separate liquids and solids No bread rice or pasta Avoid added sugars and high fat

foods VARIETY

>

>

The EndoBarrier gastrointestinal liner mimics the effects of gastric bypass surgery

Itrsquos designed to work by inserting a flexible

tube-like barrier into the duodenum amp 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

ENDO BARRIER LINER SYSTEM

B MAL- ABSORPTIVE PROCEDURES

Malabsorptive surgeries rearrange andor remove part of digestive system which then limits the amount of calories and nutrients that body can absorb Treatment with a large malabsorptive component results in the most weight loss but tend to have slightly higher complication rates

1JEJUNAL ILEAL BYPASS ndash no longer performed for high complication rates

2ILEAL TRANSPOSITION- New malabsoptive procedure on trial for treatment of DM type 2 and metabolic disorders

C COMBINATION PROCEDURES RESTRICTIVE + MALABSORBTIVE

1LAP GASTRIC BYPASS ndash ROUX-EN- Y ndash more malabsorption than the restrictive

2MINI- GASTRIC BYPASS- mainly restrictive

3DUODENAL SWITCH ndash the sleeve stomach is the restrictive portion ampthe intestinal bypass (duodenal switch) is the malabsorptive component

When surgery combines both restrictive and malabsorptive techniques it is know as a ldquocombinationrdquo procedure Most types of bariatric surgery carry at least a small element of both components but the following surgeries achieve a notable portion of weight loss from eachhellip

1 LAP GASTRIC BYPASS LGB

The Roux-en-Y gastric bypass(known simply as the LRYGBP) is the most commonly performed procedure

It primarily causesweight loss by restricting thefood intake however there ismore amount of mal absorption that occurs with this operation

GASTRIC BYPASS LRYGBP

bullThe stomach is stapled into2 pieces one small and one large The small piece becomes the ldquonewrdquo stomach pouch

bull The larger portion of the stomach stays in place however will lie dormant for the remainder of the patientrsquos life

GASTRIC BYPASS LGB

bull The small intestine (the jejunum) is divided using a surgical staplerApprox 50-70 cm from the DJ Junction

GASTRIC BYPASS LGB

Y- LIMB BP LIMB

bull The end of the Roux limb is then attached to the newly formed stomach pouch which carries food to the distal intestine

bull The Roux loop is completed by forming a jejunostomy

bull The Y limb or BPD limb carries digestive juices from the pancreas gall bladder liver and duodenum to the intestines

bull The food and the digestive juices mix where the Roux limb and Y limb meet much below say 100-150 cm from DJ

Roux limb or alimentary limb

100-150 cm

How Does the Roux-en-Y Work

Surgery factors restriction of meal size ldquodumping syndromerdquo some malabsorption decreased appetite

Patient factors calorie intake calorie expenditure

bull Most commonly performedbull Most reliable operation for long term weight lossbull Long term weight loss averages 60 to 75 percent of EBWbull Malnutrition is unusualbull Substantial improvement amp resolution in many co-morbid

obesity conditions

ADVANTAGES OF RYGBP

1 Not reversible

2 Mortality 05- 1

3 Perioperative complications 5-10

4 Stricture of gastrojejunostomy-10 (long term)

5 Long term risk of protein amp vitamin deficiency and marginal ulceration of GJA

6Long term risk of intestinal obstruction ndash 2

LAPAROSCOPIC GASTRIC BYPASSCOMPLICATIONS

Biliopancreatic Diversion (BPD)

Primarily malabsorptive but restrictive component also

First Terminal ileum is measured to a length of 50 cms marked with suture

The alimentary tract beyond the proximal part of stomach is rearranged to

include only distal 200 cm of ileum including common channel

Common channel-Distal 50 cm of terminal ileum for absorption of fat and

protein

The proximal end of ileum anastomosed to proximal end of stomach after

performing distal hemigastrectomy

Biliopancreatic Diversion with Duodenal Switch

Modification to lessen high incidence of vit b12 deficiency anastomotic stricture at gastrojejunal anastomosis

This procedure involves a sleeve gastrectomy that is then diverted at the duodenum into the ileum at a point measured proximally from the ileocecal valve (usually 250 cm)

The distal duodenum and jejunum the biliopancreatic limb are then anastomosed to the ileum at a point measured proximally from the ileocecal valve (usually 100 cm)

Common channel is 100cm Entire alimentary tract is 250 cm This is the most aggressive bypass procedure commonly offered today Major difference-Sleeve gastrectomy instead of distal hemigastrectomy

bull Most women regained normal menstrual function and most had documented

spontaneous ovulation

bull Significant improvement in hirsutism androgen profiles and about a 50 reduction in

HOMA-IR

bull Follow up for more than 2 years showed that all women resumed normal menstrual

cycles HbA1C decreased from 82 to 51 in lt 3 months

bull 78 saw improvement in metabolic syndrome amp 48 showed improvement in PCOS

2 ROLE OF BARIATRIC SURGERY IN PCOS PATIENTS

bull Decrease menstrual irregularities bull PCOS women have less hyper androgenism

bull Sex hormone binding globulin increases bull LH and FSH levels have been reported to increase

bull Ovulatory function measured by luteal LH and Progesterone secretion improved bull Leptin levels decrease reflecting improved reproductive metabolic status

bull Subclinical hypothyroidism significantly reduced

THE SAFE TIMING OF PREGNANCYoptimal or minimal time gt12 months after bariatric surgery before becoming pregnant in order to allow the rapid weight loss and metabolic changes to subside

4 BARIATRIC SURGERY IN REPRODUCTIVE WOMEN

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)

The foregut hypothesis theory ndash 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

Effect of Bariatric Surgery on Diabetes Mellitus

Combined Gastric Restriction amp Malabsorption

Operative Risks (vs cholecystectomy)

Perioperative Mortality 1-2 vs 02-08 Early Complications 10 vs 29Late Complications 20 vs 1-2

LimitationsWidening of (unbanded) gastrojejunostomyExpansion of gastric pouch 25 with nearly 100 weight regainAdaptation of limb that receives the food

SUMMARY OF ALL TYPES OF SURGERY

bull LRYGBP ndash worlds best procedure 60-70 WL dumping syndrome malnutrition

bull LAGB- low complications varying range of wt loss frequent post-op visits ( 10)

bull DSBPD- more wt loss high complications good for high BMI gt 50 malabsorption +

bull VBG(vertical band gastroplasty) ndash longest available results good wt loss improved co-morbidities right for some ptsrisks too high to justify rewards

bull SG- needs long term research 1st step procedure low risks higher wt loss lesser complications pouch could Stretch over time long staple line could cause problems in future frequency is accelerating because of technical ease 1st stage procedure before bypass

Post-surgical Complications

Anastomosis leaks or staple line leaks Pulmonary Embolism or DVT Cholelithiasis Stomal ulceration Dumping syndrome Constipation

Anastamosis Leaks

Up to 7-10 days after surgery Most common at gastrojejunostomy enteroenterostomy Roux

limb stump staple line Can lead to peritonitis sepsis possible death Presentation

Tachycardia tachypnea Fever Ab painback pain Pelvic pressure or rebound tenderness

Anastamosis Leaks

Order Gastrograffin upper GI series Subclinical cases

Bowel rest Parenteral nutrition IV antibiotic if H pylori

Clinically suspect leak Laparoscopic evaluation and leak repair

Failure to evaluate is the most common cause of preventable major long-term disability or death in bariatric surgical patients

Pulmonary Embolism

Sudden cause of death up to one month after surgery 20-30 mortality rate High risk may have vena cava filter placement prior to surgery Prophylaxis with compression stockings and LMWH Early ambulation imperitive

Pulmonary Embolism

Presentation Profound hypoxia Hypotension Signs of sepsis

Immediate spiral chest CT Abdominal exploration if too large for machine No pathology start anticoagulation Too largehelliphellipNO SURGERY

Cholelithiasis

Up to 36 of patients within 6 months post-op Bile stasis leads to increased sludge and gallstones Prophylactic cholecystectomy prior to surgery if

evidence of existing sludge or stones Prevent post-operative disease with concurrent bariatric

surgery and cholecystectomy Prophylactic use of urosidol

Expensive and unpalatable

Stomal Ulceration

12-15 within 2-4 mos Post-surgery Etiology

Overabundant acid in pouch leads to excessive acid passing through stoma

Pouch tension and staple line breakdown NSAID use

Presentation Dyspepsia vomiting Epigastric or retrosternal pain

Stomal Ulceration

Treatment PPI carafate Antibiotics if H Pylori Avoid NSAIDS alcohol smoking

If no response to treatment Endoscopy Back to surgery for pouch revision or staple line repair

Dumping Syndrome

More than 15 patients Hypotention Tachycardia Lightheadedness syncope Flushing Abdominal cramping and diarrhea Nausea and vomiting

Dumping Syndrome

Occurs with high dose simple sugar ingestion Sugar in small intestine causes osmotic overload and fluid

shift from blood to intestine Increased intestinal volume leads to watery diarrhea Decreased blood volume leads to systemic changes Patient education

Eat slowly Avoid drinking before during and not until 30 minutes after meals

Constipation

Most common complaint Causes

Dehydration and decreased fluid intake post-operatively Increased metabolic water needs Calcium and iron supplement use following surgery

Treat with increased fluids and stool softeners

Nutritional Consequences

Iron deficiency anemia B12 deficiency Folate deficiency Calcium and Vitamin D deficiency

Not seen with purely restrictive surgeries

Iron deficiency and anemia

Common following RYGB As high as 49 of patients Multifactorial cause

Low gastric acid levels prohibit iron cleavage from food Absorption inhibited because no nutrient exposure to duodenum or

proximal jejunum Decrease in iron-rich food consumption due to intolerance

Treat with oral supplementation of ferrous sulfate or ferrous gluconate

Vitamin B12 deficiency

Up to 70 of patients Lack of hydrochloric acid and pepsin in stomach

Prevents B12 cleavage from food Affects secretion of intrinsic factor thus B12 absorption

Intolerance to meat and milk Oral supplementation usually adequate otherwise IM injections used

Folate Deficiency

40 of gastric bypass patients Complete absorption requires B12 Absorption dependent on HCl and upper 13 stomach Deficiency generally caused by decreased consumption Oral supplementation

Vitamin D and Calcium Deficiency

Vitamin D deficiency is common among obese people Calcium absorption decreased because duodenum is

bypassed Intolerance to dairy foods high in calcium Vitamin D is required for Ca++ absorption Prolonged deficiencies lead to

Bone resorption osteomalacia osteoporosis Treat with calcium citrate supplementation and 2 weekly

doses of Vitamin D

Nutritional Implications of Various Bariatric Surgeries(34)

bull RYGB Malabsorption of Vit B12 Vit B1 (thiamin) Vit D Vit K Folate Iron Calcium

bull LAGB Folic Acid deficiency

bull BPD and BPDDS Vit A D E and K deficiency Protein-Calorie Malnutrition Malabsorption of

Calcium Zinc Selenium Sodium Potassium Chloride Phosphorus Magnesium

Recommended Daily Supplements(4)

Multivitamin with iron (prenatal vitamin will have adeq amount of folic acid)

Calcium (citrate) with vitamin D (1200-1500 mg calcium with 800-1000 IU vitamin D)

Oral vitamin B12 (500-1000 mcg) Iron (65 mgday in elemental form)

Vitamin C (to increase absorption of Iron) Thiamin (10 mgday)

Diet Recommendations(3)

Reduce food volume Chew food very well Slow pace of eating No liquids with meals Encourage fruits and vegetables as diet progresses Include high protein foods (at least 60gday) may need protein

supplements

Diet Progression Gastric Bypass

Stage 1 Clear liquids and protein supplement (1 week)

Stage 2No concentrated sweets low fat puree diet ( 3 weeks)

Stage 3 Regular texture weight reduction diet

Diet Progression Lap - Band

Stage 1 Clear liquids and protein supplement ( 2 weeks)

Stage 2 No concentrated sweets low fat puree diet (2weeks)

Stage 3 Regular texture weight reduction diet

Stage 1

Only clear liquids allowed Avoid sweetened beverages Sip very slowly No straws Avoid caffeinated carbonated and alcoholic beverages STOP drinking if you feel fullness pain or discomfort

Protein supplements

Begin the day after you go home from Hospital

Minimum protein target 70gmsday

May use powder or pre-mixed liquid forms (Whey protein is preferred)

Protein pills may not be used

Vitamin and Mineral Supplements

Gastric bypass patients In addition to eating much less food gastric bypass patients will also

absorb vitamins and minerals differently after surgery They will require daily multivitamin calcium and iron

supplementation for the rest of your life

Vitamin and Mineral Supplements

Lap-Bandreg patients

Require a multivitamin with minerals daily

It may be necessary to take additional vitamins and minerals eg calcium iron folateB1 B12These will be prescribed as needed

Stage 2 dietPUREE

Puree diet

Regular scheduled meals Avoid meal skipping Plan meals in advance Eat Slowly Eat protein foods first Moisten meats Use liquid protein as supplement not as meal replacement

Measure 2 oz portions at each meal eating when full Separate liquids and solids No bread rice or pasta Avoid added sugars and high fat

foods VARIETY

The EndoBarrier gastrointestinal liner mimics the effects of gastric bypass surgery

Itrsquos designed to work by inserting a flexible

tube-like barrier into the duodenum amp 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

ENDO BARRIER LINER SYSTEM

B MAL- ABSORPTIVE PROCEDURES

Malabsorptive surgeries rearrange andor remove part of digestive system which then limits the amount of calories and nutrients that body can absorb Treatment with a large malabsorptive component results in the most weight loss but tend to have slightly higher complication rates

1JEJUNAL ILEAL BYPASS ndash no longer performed for high complication rates

2ILEAL TRANSPOSITION- New malabsoptive procedure on trial for treatment of DM type 2 and metabolic disorders

C COMBINATION PROCEDURES RESTRICTIVE + MALABSORBTIVE

1LAP GASTRIC BYPASS ndash ROUX-EN- Y ndash more malabsorption than the restrictive

2MINI- GASTRIC BYPASS- mainly restrictive

3DUODENAL SWITCH ndash the sleeve stomach is the restrictive portion ampthe intestinal bypass (duodenal switch) is the malabsorptive component

When surgery combines both restrictive and malabsorptive techniques it is know as a ldquocombinationrdquo procedure Most types of bariatric surgery carry at least a small element of both components but the following surgeries achieve a notable portion of weight loss from eachhellip

1 LAP GASTRIC BYPASS LGB

The Roux-en-Y gastric bypass(known simply as the LRYGBP) is the most commonly performed procedure

It primarily causesweight loss by restricting thefood intake however there ismore amount of mal absorption that occurs with this operation

GASTRIC BYPASS LRYGBP

bullThe stomach is stapled into2 pieces one small and one large The small piece becomes the ldquonewrdquo stomach pouch

bull The larger portion of the stomach stays in place however will lie dormant for the remainder of the patientrsquos life

GASTRIC BYPASS LGB

bull The small intestine (the jejunum) is divided using a surgical staplerApprox 50-70 cm from the DJ Junction

GASTRIC BYPASS LGB

Y- LIMB BP LIMB

bull The end of the Roux limb is then attached to the newly formed stomach pouch which carries food to the distal intestine

bull The Roux loop is completed by forming a jejunostomy

bull The Y limb or BPD limb carries digestive juices from the pancreas gall bladder liver and duodenum to the intestines

bull The food and the digestive juices mix where the Roux limb and Y limb meet much below say 100-150 cm from DJ

Roux limb or alimentary limb

100-150 cm

How Does the Roux-en-Y Work

Surgery factors restriction of meal size ldquodumping syndromerdquo some malabsorption decreased appetite

Patient factors calorie intake calorie expenditure

bull Most commonly performedbull Most reliable operation for long term weight lossbull Long term weight loss averages 60 to 75 percent of EBWbull Malnutrition is unusualbull Substantial improvement amp resolution in many co-morbid

obesity conditions

ADVANTAGES OF RYGBP

1 Not reversible

2 Mortality 05- 1

3 Perioperative complications 5-10

4 Stricture of gastrojejunostomy-10 (long term)

5 Long term risk of protein amp vitamin deficiency and marginal ulceration of GJA

6Long term risk of intestinal obstruction ndash 2

LAPAROSCOPIC GASTRIC BYPASSCOMPLICATIONS

Biliopancreatic Diversion (BPD)

Primarily malabsorptive but restrictive component also

First Terminal ileum is measured to a length of 50 cms marked with suture

The alimentary tract beyond the proximal part of stomach is rearranged to

include only distal 200 cm of ileum including common channel

Common channel-Distal 50 cm of terminal ileum for absorption of fat and

protein

The proximal end of ileum anastomosed to proximal end of stomach after

performing distal hemigastrectomy

Biliopancreatic Diversion with Duodenal Switch

Modification to lessen high incidence of vit b12 deficiency anastomotic stricture at gastrojejunal anastomosis

This procedure involves a sleeve gastrectomy that is then diverted at the duodenum into the ileum at a point measured proximally from the ileocecal valve (usually 250 cm)

The distal duodenum and jejunum the biliopancreatic limb are then anastomosed to the ileum at a point measured proximally from the ileocecal valve (usually 100 cm)

Common channel is 100cm Entire alimentary tract is 250 cm This is the most aggressive bypass procedure commonly offered today Major difference-Sleeve gastrectomy instead of distal hemigastrectomy

bull Most women regained normal menstrual function and most had documented

spontaneous ovulation

bull Significant improvement in hirsutism androgen profiles and about a 50 reduction in

HOMA-IR

bull Follow up for more than 2 years showed that all women resumed normal menstrual

cycles HbA1C decreased from 82 to 51 in lt 3 months

bull 78 saw improvement in metabolic syndrome amp 48 showed improvement in PCOS

2 ROLE OF BARIATRIC SURGERY IN PCOS PATIENTS

bull Decrease menstrual irregularities bull PCOS women have less hyper androgenism

bull Sex hormone binding globulin increases bull LH and FSH levels have been reported to increase

bull Ovulatory function measured by luteal LH and Progesterone secretion improved bull Leptin levels decrease reflecting improved reproductive metabolic status

bull Subclinical hypothyroidism significantly reduced

THE SAFE TIMING OF PREGNANCYoptimal or minimal time gt12 months after bariatric surgery before becoming pregnant in order to allow the rapid weight loss and metabolic changes to subside

4 BARIATRIC SURGERY IN REPRODUCTIVE WOMEN

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)

The foregut hypothesis theory ndash 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

Effect of Bariatric Surgery on Diabetes Mellitus

Combined Gastric Restriction amp Malabsorption

Operative Risks (vs cholecystectomy)

Perioperative Mortality 1-2 vs 02-08 Early Complications 10 vs 29Late Complications 20 vs 1-2

LimitationsWidening of (unbanded) gastrojejunostomyExpansion of gastric pouch 25 with nearly 100 weight regainAdaptation of limb that receives the food

SUMMARY OF ALL TYPES OF SURGERY

bull LRYGBP ndash worlds best procedure 60-70 WL dumping syndrome malnutrition

bull LAGB- low complications varying range of wt loss frequent post-op visits ( 10)

bull DSBPD- more wt loss high complications good for high BMI gt 50 malabsorption +

bull VBG(vertical band gastroplasty) ndash longest available results good wt loss improved co-morbidities right for some ptsrisks too high to justify rewards

bull SG- needs long term research 1st step procedure low risks higher wt loss lesser complications pouch could Stretch over time long staple line could cause problems in future frequency is accelerating because of technical ease 1st stage procedure before bypass

Post-surgical Complications

Anastomosis leaks or staple line leaks Pulmonary Embolism or DVT Cholelithiasis Stomal ulceration Dumping syndrome Constipation

Anastamosis Leaks

Up to 7-10 days after surgery Most common at gastrojejunostomy enteroenterostomy Roux

limb stump staple line Can lead to peritonitis sepsis possible death Presentation

Tachycardia tachypnea Fever Ab painback pain Pelvic pressure or rebound tenderness

Anastamosis Leaks

Order Gastrograffin upper GI series Subclinical cases

Bowel rest Parenteral nutrition IV antibiotic if H pylori

Clinically suspect leak Laparoscopic evaluation and leak repair

Failure to evaluate is the most common cause of preventable major long-term disability or death in bariatric surgical patients

Pulmonary Embolism

Sudden cause of death up to one month after surgery 20-30 mortality rate High risk may have vena cava filter placement prior to surgery Prophylaxis with compression stockings and LMWH Early ambulation imperitive

Pulmonary Embolism

Presentation Profound hypoxia Hypotension Signs of sepsis

Immediate spiral chest CT Abdominal exploration if too large for machine No pathology start anticoagulation Too largehelliphellipNO SURGERY

Cholelithiasis

Up to 36 of patients within 6 months post-op Bile stasis leads to increased sludge and gallstones Prophylactic cholecystectomy prior to surgery if

evidence of existing sludge or stones Prevent post-operative disease with concurrent bariatric

surgery and cholecystectomy Prophylactic use of urosidol

Expensive and unpalatable

Stomal Ulceration

12-15 within 2-4 mos Post-surgery Etiology

Overabundant acid in pouch leads to excessive acid passing through stoma

Pouch tension and staple line breakdown NSAID use

Presentation Dyspepsia vomiting Epigastric or retrosternal pain

Stomal Ulceration

Treatment PPI carafate Antibiotics if H Pylori Avoid NSAIDS alcohol smoking

If no response to treatment Endoscopy Back to surgery for pouch revision or staple line repair

Dumping Syndrome

More than 15 patients Hypotention Tachycardia Lightheadedness syncope Flushing Abdominal cramping and diarrhea Nausea and vomiting

Dumping Syndrome

Occurs with high dose simple sugar ingestion Sugar in small intestine causes osmotic overload and fluid

shift from blood to intestine Increased intestinal volume leads to watery diarrhea Decreased blood volume leads to systemic changes Patient education

Eat slowly Avoid drinking before during and not until 30 minutes after meals

Constipation

Most common complaint Causes

Dehydration and decreased fluid intake post-operatively Increased metabolic water needs Calcium and iron supplement use following surgery

Treat with increased fluids and stool softeners

Nutritional Consequences

Iron deficiency anemia B12 deficiency Folate deficiency Calcium and Vitamin D deficiency

Not seen with purely restrictive surgeries

Iron deficiency and anemia

Common following RYGB As high as 49 of patients Multifactorial cause

Low gastric acid levels prohibit iron cleavage from food Absorption inhibited because no nutrient exposure to duodenum or

proximal jejunum Decrease in iron-rich food consumption due to intolerance

Treat with oral supplementation of ferrous sulfate or ferrous gluconate

Vitamin B12 deficiency

Up to 70 of patients Lack of hydrochloric acid and pepsin in stomach

Prevents B12 cleavage from food Affects secretion of intrinsic factor thus B12 absorption

Intolerance to meat and milk Oral supplementation usually adequate otherwise IM injections used

Folate Deficiency

40 of gastric bypass patients Complete absorption requires B12 Absorption dependent on HCl and upper 13 stomach Deficiency generally caused by decreased consumption Oral supplementation

Vitamin D and Calcium Deficiency

Vitamin D deficiency is common among obese people Calcium absorption decreased because duodenum is

bypassed Intolerance to dairy foods high in calcium Vitamin D is required for Ca++ absorption Prolonged deficiencies lead to

Bone resorption osteomalacia osteoporosis Treat with calcium citrate supplementation and 2 weekly

doses of Vitamin D

Nutritional Implications of Various Bariatric Surgeries(34)

bull RYGB Malabsorption of Vit B12 Vit B1 (thiamin) Vit D Vit K Folate Iron Calcium

bull LAGB Folic Acid deficiency

bull BPD and BPDDS Vit A D E and K deficiency Protein-Calorie Malnutrition Malabsorption of

Calcium Zinc Selenium Sodium Potassium Chloride Phosphorus Magnesium

Recommended Daily Supplements(4)

Multivitamin with iron (prenatal vitamin will have adeq amount of folic acid)

Calcium (citrate) with vitamin D (1200-1500 mg calcium with 800-1000 IU vitamin D)

Oral vitamin B12 (500-1000 mcg) Iron (65 mgday in elemental form)

Vitamin C (to increase absorption of Iron) Thiamin (10 mgday)

Diet Recommendations(3)

Reduce food volume Chew food very well Slow pace of eating No liquids with meals Encourage fruits and vegetables as diet progresses Include high protein foods (at least 60gday) may need protein

supplements

Diet Progression Gastric Bypass

Stage 1 Clear liquids and protein supplement (1 week)

Stage 2No concentrated sweets low fat puree diet ( 3 weeks)

Stage 3 Regular texture weight reduction diet

Diet Progression Lap - Band

Stage 1 Clear liquids and protein supplement ( 2 weeks)

Stage 2 No concentrated sweets low fat puree diet (2weeks)

Stage 3 Regular texture weight reduction diet

Stage 1

Only clear liquids allowed Avoid sweetened beverages Sip very slowly No straws Avoid caffeinated carbonated and alcoholic beverages STOP drinking if you feel fullness pain or discomfort

Protein supplements

Begin the day after you go home from Hospital

Minimum protein target 70gmsday

May use powder or pre-mixed liquid forms (Whey protein is preferred)

Protein pills may not be used

Vitamin and Mineral Supplements

Gastric bypass patients In addition to eating much less food gastric bypass patients will also

absorb vitamins and minerals differently after surgery They will require daily multivitamin calcium and iron

supplementation for the rest of your life

Vitamin and Mineral Supplements

Lap-Bandreg patients

Require a multivitamin with minerals daily

It may be necessary to take additional vitamins and minerals eg calcium iron folateB1 B12These will be prescribed as needed

Stage 2 dietPUREE

Puree diet

Regular scheduled meals Avoid meal skipping Plan meals in advance Eat Slowly Eat protein foods first Moisten meats Use liquid protein as supplement not as meal replacement

Measure 2 oz portions at each meal eating when full Separate liquids and solids No bread rice or pasta Avoid added sugars and high fat

foods VARIETY

B MAL- ABSORPTIVE PROCEDURES

Malabsorptive surgeries rearrange andor remove part of digestive system which then limits the amount of calories and nutrients that body can absorb Treatment with a large malabsorptive component results in the most weight loss but tend to have slightly higher complication rates

1JEJUNAL ILEAL BYPASS ndash no longer performed for high complication rates

2ILEAL TRANSPOSITION- New malabsoptive procedure on trial for treatment of DM type 2 and metabolic disorders

C COMBINATION PROCEDURES RESTRICTIVE + MALABSORBTIVE

1LAP GASTRIC BYPASS ndash ROUX-EN- Y ndash more malabsorption than the restrictive

2MINI- GASTRIC BYPASS- mainly restrictive

3DUODENAL SWITCH ndash the sleeve stomach is the restrictive portion ampthe intestinal bypass (duodenal switch) is the malabsorptive component

When surgery combines both restrictive and malabsorptive techniques it is know as a ldquocombinationrdquo procedure Most types of bariatric surgery carry at least a small element of both components but the following surgeries achieve a notable portion of weight loss from eachhellip

1 LAP GASTRIC BYPASS LGB

The Roux-en-Y gastric bypass(known simply as the LRYGBP) is the most commonly performed procedure

It primarily causesweight loss by restricting thefood intake however there ismore amount of mal absorption that occurs with this operation

GASTRIC BYPASS LRYGBP

bullThe stomach is stapled into2 pieces one small and one large The small piece becomes the ldquonewrdquo stomach pouch

bull The larger portion of the stomach stays in place however will lie dormant for the remainder of the patientrsquos life

GASTRIC BYPASS LGB

bull The small intestine (the jejunum) is divided using a surgical staplerApprox 50-70 cm from the DJ Junction

GASTRIC BYPASS LGB

Y- LIMB BP LIMB

bull The end of the Roux limb is then attached to the newly formed stomach pouch which carries food to the distal intestine

bull The Roux loop is completed by forming a jejunostomy

bull The Y limb or BPD limb carries digestive juices from the pancreas gall bladder liver and duodenum to the intestines

bull The food and the digestive juices mix where the Roux limb and Y limb meet much below say 100-150 cm from DJ

Roux limb or alimentary limb

100-150 cm

How Does the Roux-en-Y Work

Surgery factors restriction of meal size ldquodumping syndromerdquo some malabsorption decreased appetite

Patient factors calorie intake calorie expenditure

bull Most commonly performedbull Most reliable operation for long term weight lossbull Long term weight loss averages 60 to 75 percent of EBWbull Malnutrition is unusualbull Substantial improvement amp resolution in many co-morbid

obesity conditions

ADVANTAGES OF RYGBP

1 Not reversible

2 Mortality 05- 1

3 Perioperative complications 5-10

4 Stricture of gastrojejunostomy-10 (long term)

5 Long term risk of protein amp vitamin deficiency and marginal ulceration of GJA

6Long term risk of intestinal obstruction ndash 2

LAPAROSCOPIC GASTRIC BYPASSCOMPLICATIONS

Biliopancreatic Diversion (BPD)

Primarily malabsorptive but restrictive component also

First Terminal ileum is measured to a length of 50 cms marked with suture

The alimentary tract beyond the proximal part of stomach is rearranged to

include only distal 200 cm of ileum including common channel

Common channel-Distal 50 cm of terminal ileum for absorption of fat and

protein

The proximal end of ileum anastomosed to proximal end of stomach after

performing distal hemigastrectomy

Biliopancreatic Diversion with Duodenal Switch

Modification to lessen high incidence of vit b12 deficiency anastomotic stricture at gastrojejunal anastomosis

This procedure involves a sleeve gastrectomy that is then diverted at the duodenum into the ileum at a point measured proximally from the ileocecal valve (usually 250 cm)

The distal duodenum and jejunum the biliopancreatic limb are then anastomosed to the ileum at a point measured proximally from the ileocecal valve (usually 100 cm)

Common channel is 100cm Entire alimentary tract is 250 cm This is the most aggressive bypass procedure commonly offered today Major difference-Sleeve gastrectomy instead of distal hemigastrectomy

bull Most women regained normal menstrual function and most had documented

spontaneous ovulation

bull Significant improvement in hirsutism androgen profiles and about a 50 reduction in

HOMA-IR

bull Follow up for more than 2 years showed that all women resumed normal menstrual

cycles HbA1C decreased from 82 to 51 in lt 3 months

bull 78 saw improvement in metabolic syndrome amp 48 showed improvement in PCOS

2 ROLE OF BARIATRIC SURGERY IN PCOS PATIENTS

bull Decrease menstrual irregularities bull PCOS women have less hyper androgenism

bull Sex hormone binding globulin increases bull LH and FSH levels have been reported to increase

bull Ovulatory function measured by luteal LH and Progesterone secretion improved bull Leptin levels decrease reflecting improved reproductive metabolic status

bull Subclinical hypothyroidism significantly reduced

THE SAFE TIMING OF PREGNANCYoptimal or minimal time gt12 months after bariatric surgery before becoming pregnant in order to allow the rapid weight loss and metabolic changes to subside

4 BARIATRIC SURGERY IN REPRODUCTIVE WOMEN

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)

The foregut hypothesis theory ndash 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

Effect of Bariatric Surgery on Diabetes Mellitus

Combined Gastric Restriction amp Malabsorption

Operative Risks (vs cholecystectomy)

Perioperative Mortality 1-2 vs 02-08 Early Complications 10 vs 29Late Complications 20 vs 1-2

LimitationsWidening of (unbanded) gastrojejunostomyExpansion of gastric pouch 25 with nearly 100 weight regainAdaptation of limb that receives the food

SUMMARY OF ALL TYPES OF SURGERY

bull LRYGBP ndash worlds best procedure 60-70 WL dumping syndrome malnutrition

bull LAGB- low complications varying range of wt loss frequent post-op visits ( 10)

bull DSBPD- more wt loss high complications good for high BMI gt 50 malabsorption +

bull VBG(vertical band gastroplasty) ndash longest available results good wt loss improved co-morbidities right for some ptsrisks too high to justify rewards

bull SG- needs long term research 1st step procedure low risks higher wt loss lesser complications pouch could Stretch over time long staple line could cause problems in future frequency is accelerating because of technical ease 1st stage procedure before bypass

Post-surgical Complications

Anastomosis leaks or staple line leaks Pulmonary Embolism or DVT Cholelithiasis Stomal ulceration Dumping syndrome Constipation

Anastamosis Leaks

Up to 7-10 days after surgery Most common at gastrojejunostomy enteroenterostomy Roux

limb stump staple line Can lead to peritonitis sepsis possible death Presentation

Tachycardia tachypnea Fever Ab painback pain Pelvic pressure or rebound tenderness

Anastamosis Leaks

Order Gastrograffin upper GI series Subclinical cases

Bowel rest Parenteral nutrition IV antibiotic if H pylori

Clinically suspect leak Laparoscopic evaluation and leak repair

Failure to evaluate is the most common cause of preventable major long-term disability or death in bariatric surgical patients

Pulmonary Embolism

Sudden cause of death up to one month after surgery 20-30 mortality rate High risk may have vena cava filter placement prior to surgery Prophylaxis with compression stockings and LMWH Early ambulation imperitive

Pulmonary Embolism

Presentation Profound hypoxia Hypotension Signs of sepsis

Immediate spiral chest CT Abdominal exploration if too large for machine No pathology start anticoagulation Too largehelliphellipNO SURGERY

Cholelithiasis

Up to 36 of patients within 6 months post-op Bile stasis leads to increased sludge and gallstones Prophylactic cholecystectomy prior to surgery if

evidence of existing sludge or stones Prevent post-operative disease with concurrent bariatric

surgery and cholecystectomy Prophylactic use of urosidol

Expensive and unpalatable

Stomal Ulceration

12-15 within 2-4 mos Post-surgery Etiology

Overabundant acid in pouch leads to excessive acid passing through stoma

Pouch tension and staple line breakdown NSAID use

Presentation Dyspepsia vomiting Epigastric or retrosternal pain

Stomal Ulceration

Treatment PPI carafate Antibiotics if H Pylori Avoid NSAIDS alcohol smoking

If no response to treatment Endoscopy Back to surgery for pouch revision or staple line repair

Dumping Syndrome

More than 15 patients Hypotention Tachycardia Lightheadedness syncope Flushing Abdominal cramping and diarrhea Nausea and vomiting

Dumping Syndrome

Occurs with high dose simple sugar ingestion Sugar in small intestine causes osmotic overload and fluid

shift from blood to intestine Increased intestinal volume leads to watery diarrhea Decreased blood volume leads to systemic changes Patient education

Eat slowly Avoid drinking before during and not until 30 minutes after meals

Constipation

Most common complaint Causes

Dehydration and decreased fluid intake post-operatively Increased metabolic water needs Calcium and iron supplement use following surgery

Treat with increased fluids and stool softeners

Nutritional Consequences

Iron deficiency anemia B12 deficiency Folate deficiency Calcium and Vitamin D deficiency

Not seen with purely restrictive surgeries

Iron deficiency and anemia

Common following RYGB As high as 49 of patients Multifactorial cause

Low gastric acid levels prohibit iron cleavage from food Absorption inhibited because no nutrient exposure to duodenum or

proximal jejunum Decrease in iron-rich food consumption due to intolerance

Treat with oral supplementation of ferrous sulfate or ferrous gluconate

Vitamin B12 deficiency

Up to 70 of patients Lack of hydrochloric acid and pepsin in stomach

Prevents B12 cleavage from food Affects secretion of intrinsic factor thus B12 absorption

Intolerance to meat and milk Oral supplementation usually adequate otherwise IM injections used

Folate Deficiency

40 of gastric bypass patients Complete absorption requires B12 Absorption dependent on HCl and upper 13 stomach Deficiency generally caused by decreased consumption Oral supplementation

Vitamin D and Calcium Deficiency

Vitamin D deficiency is common among obese people Calcium absorption decreased because duodenum is

bypassed Intolerance to dairy foods high in calcium Vitamin D is required for Ca++ absorption Prolonged deficiencies lead to

Bone resorption osteomalacia osteoporosis Treat with calcium citrate supplementation and 2 weekly

doses of Vitamin D

Nutritional Implications of Various Bariatric Surgeries(34)

bull RYGB Malabsorption of Vit B12 Vit B1 (thiamin) Vit D Vit K Folate Iron Calcium

bull LAGB Folic Acid deficiency

bull BPD and BPDDS Vit A D E and K deficiency Protein-Calorie Malnutrition Malabsorption of

Calcium Zinc Selenium Sodium Potassium Chloride Phosphorus Magnesium

Recommended Daily Supplements(4)

Multivitamin with iron (prenatal vitamin will have adeq amount of folic acid)

Calcium (citrate) with vitamin D (1200-1500 mg calcium with 800-1000 IU vitamin D)

Oral vitamin B12 (500-1000 mcg) Iron (65 mgday in elemental form)

Vitamin C (to increase absorption of Iron) Thiamin (10 mgday)

Diet Recommendations(3)

Reduce food volume Chew food very well Slow pace of eating No liquids with meals Encourage fruits and vegetables as diet progresses Include high protein foods (at least 60gday) may need protein

supplements

Diet Progression Gastric Bypass

Stage 1 Clear liquids and protein supplement (1 week)

Stage 2No concentrated sweets low fat puree diet ( 3 weeks)

Stage 3 Regular texture weight reduction diet

Diet Progression Lap - Band

Stage 1 Clear liquids and protein supplement ( 2 weeks)

Stage 2 No concentrated sweets low fat puree diet (2weeks)

Stage 3 Regular texture weight reduction diet

Stage 1

Only clear liquids allowed Avoid sweetened beverages Sip very slowly No straws Avoid caffeinated carbonated and alcoholic beverages STOP drinking if you feel fullness pain or discomfort

Protein supplements

Begin the day after you go home from Hospital

Minimum protein target 70gmsday

May use powder or pre-mixed liquid forms (Whey protein is preferred)

Protein pills may not be used

Vitamin and Mineral Supplements

Gastric bypass patients In addition to eating much less food gastric bypass patients will also

absorb vitamins and minerals differently after surgery They will require daily multivitamin calcium and iron

supplementation for the rest of your life

Vitamin and Mineral Supplements

Lap-Bandreg patients

Require a multivitamin with minerals daily

It may be necessary to take additional vitamins and minerals eg calcium iron folateB1 B12These will be prescribed as needed

Stage 2 dietPUREE

Puree diet

Regular scheduled meals Avoid meal skipping Plan meals in advance Eat Slowly Eat protein foods first Moisten meats Use liquid protein as supplement not as meal replacement

Measure 2 oz portions at each meal eating when full Separate liquids and solids No bread rice or pasta Avoid added sugars and high fat

foods VARIETY

C COMBINATION PROCEDURES RESTRICTIVE + MALABSORBTIVE

1LAP GASTRIC BYPASS ndash ROUX-EN- Y ndash more malabsorption than the restrictive

2MINI- GASTRIC BYPASS- mainly restrictive

3DUODENAL SWITCH ndash the sleeve stomach is the restrictive portion ampthe intestinal bypass (duodenal switch) is the malabsorptive component

When surgery combines both restrictive and malabsorptive techniques it is know as a ldquocombinationrdquo procedure Most types of bariatric surgery carry at least a small element of both components but the following surgeries achieve a notable portion of weight loss from eachhellip

1 LAP GASTRIC BYPASS LGB

The Roux-en-Y gastric bypass(known simply as the LRYGBP) is the most commonly performed procedure

It primarily causesweight loss by restricting thefood intake however there ismore amount of mal absorption that occurs with this operation

GASTRIC BYPASS LRYGBP

bullThe stomach is stapled into2 pieces one small and one large The small piece becomes the ldquonewrdquo stomach pouch

bull The larger portion of the stomach stays in place however will lie dormant for the remainder of the patientrsquos life

GASTRIC BYPASS LGB

bull The small intestine (the jejunum) is divided using a surgical staplerApprox 50-70 cm from the DJ Junction

GASTRIC BYPASS LGB

Y- LIMB BP LIMB

bull The end of the Roux limb is then attached to the newly formed stomach pouch which carries food to the distal intestine

bull The Roux loop is completed by forming a jejunostomy

bull The Y limb or BPD limb carries digestive juices from the pancreas gall bladder liver and duodenum to the intestines

bull The food and the digestive juices mix where the Roux limb and Y limb meet much below say 100-150 cm from DJ

Roux limb or alimentary limb

100-150 cm

How Does the Roux-en-Y Work

Surgery factors restriction of meal size ldquodumping syndromerdquo some malabsorption decreased appetite

Patient factors calorie intake calorie expenditure

bull Most commonly performedbull Most reliable operation for long term weight lossbull Long term weight loss averages 60 to 75 percent of EBWbull Malnutrition is unusualbull Substantial improvement amp resolution in many co-morbid

obesity conditions

ADVANTAGES OF RYGBP

1 Not reversible

2 Mortality 05- 1

3 Perioperative complications 5-10

4 Stricture of gastrojejunostomy-10 (long term)

5 Long term risk of protein amp vitamin deficiency and marginal ulceration of GJA

6Long term risk of intestinal obstruction ndash 2

LAPAROSCOPIC GASTRIC BYPASSCOMPLICATIONS

Biliopancreatic Diversion (BPD)

Primarily malabsorptive but restrictive component also

First Terminal ileum is measured to a length of 50 cms marked with suture

The alimentary tract beyond the proximal part of stomach is rearranged to

include only distal 200 cm of ileum including common channel

Common channel-Distal 50 cm of terminal ileum for absorption of fat and

protein

The proximal end of ileum anastomosed to proximal end of stomach after

performing distal hemigastrectomy

Biliopancreatic Diversion with Duodenal Switch

Modification to lessen high incidence of vit b12 deficiency anastomotic stricture at gastrojejunal anastomosis

This procedure involves a sleeve gastrectomy that is then diverted at the duodenum into the ileum at a point measured proximally from the ileocecal valve (usually 250 cm)

The distal duodenum and jejunum the biliopancreatic limb are then anastomosed to the ileum at a point measured proximally from the ileocecal valve (usually 100 cm)

Common channel is 100cm Entire alimentary tract is 250 cm This is the most aggressive bypass procedure commonly offered today Major difference-Sleeve gastrectomy instead of distal hemigastrectomy

bull Most women regained normal menstrual function and most had documented

spontaneous ovulation

bull Significant improvement in hirsutism androgen profiles and about a 50 reduction in

HOMA-IR

bull Follow up for more than 2 years showed that all women resumed normal menstrual

cycles HbA1C decreased from 82 to 51 in lt 3 months

bull 78 saw improvement in metabolic syndrome amp 48 showed improvement in PCOS

2 ROLE OF BARIATRIC SURGERY IN PCOS PATIENTS

bull Decrease menstrual irregularities bull PCOS women have less hyper androgenism

bull Sex hormone binding globulin increases bull LH and FSH levels have been reported to increase

bull Ovulatory function measured by luteal LH and Progesterone secretion improved bull Leptin levels decrease reflecting improved reproductive metabolic status

bull Subclinical hypothyroidism significantly reduced

THE SAFE TIMING OF PREGNANCYoptimal or minimal time gt12 months after bariatric surgery before becoming pregnant in order to allow the rapid weight loss and metabolic changes to subside

4 BARIATRIC SURGERY IN REPRODUCTIVE WOMEN

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)

The foregut hypothesis theory ndash 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

Effect of Bariatric Surgery on Diabetes Mellitus

Combined Gastric Restriction amp Malabsorption

Operative Risks (vs cholecystectomy)

Perioperative Mortality 1-2 vs 02-08 Early Complications 10 vs 29Late Complications 20 vs 1-2

LimitationsWidening of (unbanded) gastrojejunostomyExpansion of gastric pouch 25 with nearly 100 weight regainAdaptation of limb that receives the food

SUMMARY OF ALL TYPES OF SURGERY

bull LRYGBP ndash worlds best procedure 60-70 WL dumping syndrome malnutrition

bull LAGB- low complications varying range of wt loss frequent post-op visits ( 10)

bull DSBPD- more wt loss high complications good for high BMI gt 50 malabsorption +

bull VBG(vertical band gastroplasty) ndash longest available results good wt loss improved co-morbidities right for some ptsrisks too high to justify rewards

bull SG- needs long term research 1st step procedure low risks higher wt loss lesser complications pouch could Stretch over time long staple line could cause problems in future frequency is accelerating because of technical ease 1st stage procedure before bypass

Post-surgical Complications

Anastomosis leaks or staple line leaks Pulmonary Embolism or DVT Cholelithiasis Stomal ulceration Dumping syndrome Constipation

Anastamosis Leaks

Up to 7-10 days after surgery Most common at gastrojejunostomy enteroenterostomy Roux

limb stump staple line Can lead to peritonitis sepsis possible death Presentation

Tachycardia tachypnea Fever Ab painback pain Pelvic pressure or rebound tenderness

Anastamosis Leaks

Order Gastrograffin upper GI series Subclinical cases

Bowel rest Parenteral nutrition IV antibiotic if H pylori

Clinically suspect leak Laparoscopic evaluation and leak repair

Failure to evaluate is the most common cause of preventable major long-term disability or death in bariatric surgical patients

Pulmonary Embolism

Sudden cause of death up to one month after surgery 20-30 mortality rate High risk may have vena cava filter placement prior to surgery Prophylaxis with compression stockings and LMWH Early ambulation imperitive

Pulmonary Embolism

Presentation Profound hypoxia Hypotension Signs of sepsis

Immediate spiral chest CT Abdominal exploration if too large for machine No pathology start anticoagulation Too largehelliphellipNO SURGERY

Cholelithiasis

Up to 36 of patients within 6 months post-op Bile stasis leads to increased sludge and gallstones Prophylactic cholecystectomy prior to surgery if

evidence of existing sludge or stones Prevent post-operative disease with concurrent bariatric

surgery and cholecystectomy Prophylactic use of urosidol

Expensive and unpalatable

Stomal Ulceration

12-15 within 2-4 mos Post-surgery Etiology

Overabundant acid in pouch leads to excessive acid passing through stoma

Pouch tension and staple line breakdown NSAID use

Presentation Dyspepsia vomiting Epigastric or retrosternal pain

Stomal Ulceration

Treatment PPI carafate Antibiotics if H Pylori Avoid NSAIDS alcohol smoking

If no response to treatment Endoscopy Back to surgery for pouch revision or staple line repair

Dumping Syndrome

More than 15 patients Hypotention Tachycardia Lightheadedness syncope Flushing Abdominal cramping and diarrhea Nausea and vomiting

Dumping Syndrome

Occurs with high dose simple sugar ingestion Sugar in small intestine causes osmotic overload and fluid

shift from blood to intestine Increased intestinal volume leads to watery diarrhea Decreased blood volume leads to systemic changes Patient education

Eat slowly Avoid drinking before during and not until 30 minutes after meals

Constipation

Most common complaint Causes

Dehydration and decreased fluid intake post-operatively Increased metabolic water needs Calcium and iron supplement use following surgery

Treat with increased fluids and stool softeners

Nutritional Consequences

Iron deficiency anemia B12 deficiency Folate deficiency Calcium and Vitamin D deficiency

Not seen with purely restrictive surgeries

Iron deficiency and anemia

Common following RYGB As high as 49 of patients Multifactorial cause

Low gastric acid levels prohibit iron cleavage from food Absorption inhibited because no nutrient exposure to duodenum or

proximal jejunum Decrease in iron-rich food consumption due to intolerance

Treat with oral supplementation of ferrous sulfate or ferrous gluconate

Vitamin B12 deficiency

Up to 70 of patients Lack of hydrochloric acid and pepsin in stomach

Prevents B12 cleavage from food Affects secretion of intrinsic factor thus B12 absorption

Intolerance to meat and milk Oral supplementation usually adequate otherwise IM injections used

Folate Deficiency

40 of gastric bypass patients Complete absorption requires B12 Absorption dependent on HCl and upper 13 stomach Deficiency generally caused by decreased consumption Oral supplementation

Vitamin D and Calcium Deficiency

Vitamin D deficiency is common among obese people Calcium absorption decreased because duodenum is

bypassed Intolerance to dairy foods high in calcium Vitamin D is required for Ca++ absorption Prolonged deficiencies lead to

Bone resorption osteomalacia osteoporosis Treat with calcium citrate supplementation and 2 weekly

doses of Vitamin D

Nutritional Implications of Various Bariatric Surgeries(34)

bull RYGB Malabsorption of Vit B12 Vit B1 (thiamin) Vit D Vit K Folate Iron Calcium

bull LAGB Folic Acid deficiency

bull BPD and BPDDS Vit A D E and K deficiency Protein-Calorie Malnutrition Malabsorption of

Calcium Zinc Selenium Sodium Potassium Chloride Phosphorus Magnesium

Recommended Daily Supplements(4)

Multivitamin with iron (prenatal vitamin will have adeq amount of folic acid)

Calcium (citrate) with vitamin D (1200-1500 mg calcium with 800-1000 IU vitamin D)

Oral vitamin B12 (500-1000 mcg) Iron (65 mgday in elemental form)

Vitamin C (to increase absorption of Iron) Thiamin (10 mgday)

Diet Recommendations(3)

Reduce food volume Chew food very well Slow pace of eating No liquids with meals Encourage fruits and vegetables as diet progresses Include high protein foods (at least 60gday) may need protein

supplements

Diet Progression Gastric Bypass

Stage 1 Clear liquids and protein supplement (1 week)

Stage 2No concentrated sweets low fat puree diet ( 3 weeks)

Stage 3 Regular texture weight reduction diet

Diet Progression Lap - Band

Stage 1 Clear liquids and protein supplement ( 2 weeks)

Stage 2 No concentrated sweets low fat puree diet (2weeks)

Stage 3 Regular texture weight reduction diet

Stage 1

Only clear liquids allowed Avoid sweetened beverages Sip very slowly No straws Avoid caffeinated carbonated and alcoholic beverages STOP drinking if you feel fullness pain or discomfort

Protein supplements

Begin the day after you go home from Hospital

Minimum protein target 70gmsday

May use powder or pre-mixed liquid forms (Whey protein is preferred)

Protein pills may not be used

Vitamin and Mineral Supplements

Gastric bypass patients In addition to eating much less food gastric bypass patients will also

absorb vitamins and minerals differently after surgery They will require daily multivitamin calcium and iron

supplementation for the rest of your life

Vitamin and Mineral Supplements

Lap-Bandreg patients

Require a multivitamin with minerals daily

It may be necessary to take additional vitamins and minerals eg calcium iron folateB1 B12These will be prescribed as needed

Stage 2 dietPUREE

Puree diet

Regular scheduled meals Avoid meal skipping Plan meals in advance Eat Slowly Eat protein foods first Moisten meats Use liquid protein as supplement not as meal replacement

Measure 2 oz portions at each meal eating when full Separate liquids and solids No bread rice or pasta Avoid added sugars and high fat

foods VARIETY

1 LAP GASTRIC BYPASS LGB

The Roux-en-Y gastric bypass(known simply as the LRYGBP) is the most commonly performed procedure

It primarily causesweight loss by restricting thefood intake however there ismore amount of mal absorption that occurs with this operation

GASTRIC BYPASS LRYGBP

bullThe stomach is stapled into2 pieces one small and one large The small piece becomes the ldquonewrdquo stomach pouch

bull The larger portion of the stomach stays in place however will lie dormant for the remainder of the patientrsquos life

GASTRIC BYPASS LGB

bull The small intestine (the jejunum) is divided using a surgical staplerApprox 50-70 cm from the DJ Junction

GASTRIC BYPASS LGB

Y- LIMB BP LIMB

bull The end of the Roux limb is then attached to the newly formed stomach pouch which carries food to the distal intestine

bull The Roux loop is completed by forming a jejunostomy

bull The Y limb or BPD limb carries digestive juices from the pancreas gall bladder liver and duodenum to the intestines

bull The food and the digestive juices mix where the Roux limb and Y limb meet much below say 100-150 cm from DJ

Roux limb or alimentary limb

100-150 cm

How Does the Roux-en-Y Work

Surgery factors restriction of meal size ldquodumping syndromerdquo some malabsorption decreased appetite

Patient factors calorie intake calorie expenditure

bull Most commonly performedbull Most reliable operation for long term weight lossbull Long term weight loss averages 60 to 75 percent of EBWbull Malnutrition is unusualbull Substantial improvement amp resolution in many co-morbid

obesity conditions

ADVANTAGES OF RYGBP

1 Not reversible

2 Mortality 05- 1

3 Perioperative complications 5-10

4 Stricture of gastrojejunostomy-10 (long term)

5 Long term risk of protein amp vitamin deficiency and marginal ulceration of GJA

6Long term risk of intestinal obstruction ndash 2

LAPAROSCOPIC GASTRIC BYPASSCOMPLICATIONS

Biliopancreatic Diversion (BPD)

Primarily malabsorptive but restrictive component also

First Terminal ileum is measured to a length of 50 cms marked with suture

The alimentary tract beyond the proximal part of stomach is rearranged to

include only distal 200 cm of ileum including common channel

Common channel-Distal 50 cm of terminal ileum for absorption of fat and

protein

The proximal end of ileum anastomosed to proximal end of stomach after

performing distal hemigastrectomy

Biliopancreatic Diversion with Duodenal Switch

Modification to lessen high incidence of vit b12 deficiency anastomotic stricture at gastrojejunal anastomosis

This procedure involves a sleeve gastrectomy that is then diverted at the duodenum into the ileum at a point measured proximally from the ileocecal valve (usually 250 cm)

The distal duodenum and jejunum the biliopancreatic limb are then anastomosed to the ileum at a point measured proximally from the ileocecal valve (usually 100 cm)

Common channel is 100cm Entire alimentary tract is 250 cm This is the most aggressive bypass procedure commonly offered today Major difference-Sleeve gastrectomy instead of distal hemigastrectomy

bull Most women regained normal menstrual function and most had documented

spontaneous ovulation

bull Significant improvement in hirsutism androgen profiles and about a 50 reduction in

HOMA-IR

bull Follow up for more than 2 years showed that all women resumed normal menstrual

cycles HbA1C decreased from 82 to 51 in lt 3 months

bull 78 saw improvement in metabolic syndrome amp 48 showed improvement in PCOS

2 ROLE OF BARIATRIC SURGERY IN PCOS PATIENTS

bull Decrease menstrual irregularities bull PCOS women have less hyper androgenism

bull Sex hormone binding globulin increases bull LH and FSH levels have been reported to increase

bull Ovulatory function measured by luteal LH and Progesterone secretion improved bull Leptin levels decrease reflecting improved reproductive metabolic status

bull Subclinical hypothyroidism significantly reduced

THE SAFE TIMING OF PREGNANCYoptimal or minimal time gt12 months after bariatric surgery before becoming pregnant in order to allow the rapid weight loss and metabolic changes to subside

4 BARIATRIC SURGERY IN REPRODUCTIVE WOMEN

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)

The foregut hypothesis theory ndash 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

Effect of Bariatric Surgery on Diabetes Mellitus

Combined Gastric Restriction amp Malabsorption

Operative Risks (vs cholecystectomy)

Perioperative Mortality 1-2 vs 02-08 Early Complications 10 vs 29Late Complications 20 vs 1-2

LimitationsWidening of (unbanded) gastrojejunostomyExpansion of gastric pouch 25 with nearly 100 weight regainAdaptation of limb that receives the food

SUMMARY OF ALL TYPES OF SURGERY

bull LRYGBP ndash worlds best procedure 60-70 WL dumping syndrome malnutrition

bull LAGB- low complications varying range of wt loss frequent post-op visits ( 10)

bull DSBPD- more wt loss high complications good for high BMI gt 50 malabsorption +

bull VBG(vertical band gastroplasty) ndash longest available results good wt loss improved co-morbidities right for some ptsrisks too high to justify rewards

bull SG- needs long term research 1st step procedure low risks higher wt loss lesser complications pouch could Stretch over time long staple line could cause problems in future frequency is accelerating because of technical ease 1st stage procedure before bypass

Post-surgical Complications

Anastomosis leaks or staple line leaks Pulmonary Embolism or DVT Cholelithiasis Stomal ulceration Dumping syndrome Constipation

Anastamosis Leaks

Up to 7-10 days after surgery Most common at gastrojejunostomy enteroenterostomy Roux

limb stump staple line Can lead to peritonitis sepsis possible death Presentation

Tachycardia tachypnea Fever Ab painback pain Pelvic pressure or rebound tenderness

Anastamosis Leaks

Order Gastrograffin upper GI series Subclinical cases

Bowel rest Parenteral nutrition IV antibiotic if H pylori

Clinically suspect leak Laparoscopic evaluation and leak repair

Failure to evaluate is the most common cause of preventable major long-term disability or death in bariatric surgical patients

Pulmonary Embolism

Sudden cause of death up to one month after surgery 20-30 mortality rate High risk may have vena cava filter placement prior to surgery Prophylaxis with compression stockings and LMWH Early ambulation imperitive

Pulmonary Embolism

Presentation Profound hypoxia Hypotension Signs of sepsis

Immediate spiral chest CT Abdominal exploration if too large for machine No pathology start anticoagulation Too largehelliphellipNO SURGERY

Cholelithiasis

Up to 36 of patients within 6 months post-op Bile stasis leads to increased sludge and gallstones Prophylactic cholecystectomy prior to surgery if

evidence of existing sludge or stones Prevent post-operative disease with concurrent bariatric

surgery and cholecystectomy Prophylactic use of urosidol

Expensive and unpalatable

Stomal Ulceration

12-15 within 2-4 mos Post-surgery Etiology

Overabundant acid in pouch leads to excessive acid passing through stoma

Pouch tension and staple line breakdown NSAID use

Presentation Dyspepsia vomiting Epigastric or retrosternal pain

Stomal Ulceration

Treatment PPI carafate Antibiotics if H Pylori Avoid NSAIDS alcohol smoking

If no response to treatment Endoscopy Back to surgery for pouch revision or staple line repair

Dumping Syndrome

More than 15 patients Hypotention Tachycardia Lightheadedness syncope Flushing Abdominal cramping and diarrhea Nausea and vomiting

Dumping Syndrome

Occurs with high dose simple sugar ingestion Sugar in small intestine causes osmotic overload and fluid

shift from blood to intestine Increased intestinal volume leads to watery diarrhea Decreased blood volume leads to systemic changes Patient education

Eat slowly Avoid drinking before during and not until 30 minutes after meals

Constipation

Most common complaint Causes

Dehydration and decreased fluid intake post-operatively Increased metabolic water needs Calcium and iron supplement use following surgery

Treat with increased fluids and stool softeners

Nutritional Consequences

Iron deficiency anemia B12 deficiency Folate deficiency Calcium and Vitamin D deficiency

Not seen with purely restrictive surgeries

Iron deficiency and anemia

Common following RYGB As high as 49 of patients Multifactorial cause

Low gastric acid levels prohibit iron cleavage from food Absorption inhibited because no nutrient exposure to duodenum or

proximal jejunum Decrease in iron-rich food consumption due to intolerance

Treat with oral supplementation of ferrous sulfate or ferrous gluconate

Vitamin B12 deficiency

Up to 70 of patients Lack of hydrochloric acid and pepsin in stomach

Prevents B12 cleavage from food Affects secretion of intrinsic factor thus B12 absorption

Intolerance to meat and milk Oral supplementation usually adequate otherwise IM injections used

Folate Deficiency

40 of gastric bypass patients Complete absorption requires B12 Absorption dependent on HCl and upper 13 stomach Deficiency generally caused by decreased consumption Oral supplementation

Vitamin D and Calcium Deficiency

Vitamin D deficiency is common among obese people Calcium absorption decreased because duodenum is

bypassed Intolerance to dairy foods high in calcium Vitamin D is required for Ca++ absorption Prolonged deficiencies lead to

Bone resorption osteomalacia osteoporosis Treat with calcium citrate supplementation and 2 weekly

doses of Vitamin D

Nutritional Implications of Various Bariatric Surgeries(34)

bull RYGB Malabsorption of Vit B12 Vit B1 (thiamin) Vit D Vit K Folate Iron Calcium

bull LAGB Folic Acid deficiency

bull BPD and BPDDS Vit A D E and K deficiency Protein-Calorie Malnutrition Malabsorption of

Calcium Zinc Selenium Sodium Potassium Chloride Phosphorus Magnesium

Recommended Daily Supplements(4)

Multivitamin with iron (prenatal vitamin will have adeq amount of folic acid)

Calcium (citrate) with vitamin D (1200-1500 mg calcium with 800-1000 IU vitamin D)

Oral vitamin B12 (500-1000 mcg) Iron (65 mgday in elemental form)

Vitamin C (to increase absorption of Iron) Thiamin (10 mgday)

Diet Recommendations(3)

Reduce food volume Chew food very well Slow pace of eating No liquids with meals Encourage fruits and vegetables as diet progresses Include high protein foods (at least 60gday) may need protein

supplements

Diet Progression Gastric Bypass

Stage 1 Clear liquids and protein supplement (1 week)

Stage 2No concentrated sweets low fat puree diet ( 3 weeks)

Stage 3 Regular texture weight reduction diet

Diet Progression Lap - Band

Stage 1 Clear liquids and protein supplement ( 2 weeks)

Stage 2 No concentrated sweets low fat puree diet (2weeks)

Stage 3 Regular texture weight reduction diet

Stage 1

Only clear liquids allowed Avoid sweetened beverages Sip very slowly No straws Avoid caffeinated carbonated and alcoholic beverages STOP drinking if you feel fullness pain or discomfort

Protein supplements

Begin the day after you go home from Hospital

Minimum protein target 70gmsday

May use powder or pre-mixed liquid forms (Whey protein is preferred)

Protein pills may not be used

Vitamin and Mineral Supplements

Gastric bypass patients In addition to eating much less food gastric bypass patients will also

absorb vitamins and minerals differently after surgery They will require daily multivitamin calcium and iron

supplementation for the rest of your life

Vitamin and Mineral Supplements

Lap-Bandreg patients

Require a multivitamin with minerals daily

It may be necessary to take additional vitamins and minerals eg calcium iron folateB1 B12These will be prescribed as needed

Stage 2 dietPUREE

Puree diet

Regular scheduled meals Avoid meal skipping Plan meals in advance Eat Slowly Eat protein foods first Moisten meats Use liquid protein as supplement not as meal replacement

Measure 2 oz portions at each meal eating when full Separate liquids and solids No bread rice or pasta Avoid added sugars and high fat

foods VARIETY

GASTRIC BYPASS LRYGBP

bullThe stomach is stapled into2 pieces one small and one large The small piece becomes the ldquonewrdquo stomach pouch

bull The larger portion of the stomach stays in place however will lie dormant for the remainder of the patientrsquos life

GASTRIC BYPASS LGB

bull The small intestine (the jejunum) is divided using a surgical staplerApprox 50-70 cm from the DJ Junction

GASTRIC BYPASS LGB

Y- LIMB BP LIMB

bull The end of the Roux limb is then attached to the newly formed stomach pouch which carries food to the distal intestine

bull The Roux loop is completed by forming a jejunostomy

bull The Y limb or BPD limb carries digestive juices from the pancreas gall bladder liver and duodenum to the intestines

bull The food and the digestive juices mix where the Roux limb and Y limb meet much below say 100-150 cm from DJ

Roux limb or alimentary limb

100-150 cm

How Does the Roux-en-Y Work

Surgery factors restriction of meal size ldquodumping syndromerdquo some malabsorption decreased appetite

Patient factors calorie intake calorie expenditure

bull Most commonly performedbull Most reliable operation for long term weight lossbull Long term weight loss averages 60 to 75 percent of EBWbull Malnutrition is unusualbull Substantial improvement amp resolution in many co-morbid

obesity conditions

ADVANTAGES OF RYGBP

1 Not reversible

2 Mortality 05- 1

3 Perioperative complications 5-10

4 Stricture of gastrojejunostomy-10 (long term)

5 Long term risk of protein amp vitamin deficiency and marginal ulceration of GJA

6Long term risk of intestinal obstruction ndash 2

LAPAROSCOPIC GASTRIC BYPASSCOMPLICATIONS

Biliopancreatic Diversion (BPD)

Primarily malabsorptive but restrictive component also

First Terminal ileum is measured to a length of 50 cms marked with suture

The alimentary tract beyond the proximal part of stomach is rearranged to

include only distal 200 cm of ileum including common channel

Common channel-Distal 50 cm of terminal ileum for absorption of fat and

protein

The proximal end of ileum anastomosed to proximal end of stomach after

performing distal hemigastrectomy

Biliopancreatic Diversion with Duodenal Switch

Modification to lessen high incidence of vit b12 deficiency anastomotic stricture at gastrojejunal anastomosis

This procedure involves a sleeve gastrectomy that is then diverted at the duodenum into the ileum at a point measured proximally from the ileocecal valve (usually 250 cm)

The distal duodenum and jejunum the biliopancreatic limb are then anastomosed to the ileum at a point measured proximally from the ileocecal valve (usually 100 cm)

Common channel is 100cm Entire alimentary tract is 250 cm This is the most aggressive bypass procedure commonly offered today Major difference-Sleeve gastrectomy instead of distal hemigastrectomy

bull Most women regained normal menstrual function and most had documented

spontaneous ovulation

bull Significant improvement in hirsutism androgen profiles and about a 50 reduction in

HOMA-IR

bull Follow up for more than 2 years showed that all women resumed normal menstrual

cycles HbA1C decreased from 82 to 51 in lt 3 months

bull 78 saw improvement in metabolic syndrome amp 48 showed improvement in PCOS

2 ROLE OF BARIATRIC SURGERY IN PCOS PATIENTS

bull Decrease menstrual irregularities bull PCOS women have less hyper androgenism

bull Sex hormone binding globulin increases bull LH and FSH levels have been reported to increase

bull Ovulatory function measured by luteal LH and Progesterone secretion improved bull Leptin levels decrease reflecting improved reproductive metabolic status

bull Subclinical hypothyroidism significantly reduced

THE SAFE TIMING OF PREGNANCYoptimal or minimal time gt12 months after bariatric surgery before becoming pregnant in order to allow the rapid weight loss and metabolic changes to subside

4 BARIATRIC SURGERY IN REPRODUCTIVE WOMEN

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)

The foregut hypothesis theory ndash 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

Effect of Bariatric Surgery on Diabetes Mellitus

Combined Gastric Restriction amp Malabsorption

Operative Risks (vs cholecystectomy)

Perioperative Mortality 1-2 vs 02-08 Early Complications 10 vs 29Late Complications 20 vs 1-2

LimitationsWidening of (unbanded) gastrojejunostomyExpansion of gastric pouch 25 with nearly 100 weight regainAdaptation of limb that receives the food

SUMMARY OF ALL TYPES OF SURGERY

bull LRYGBP ndash worlds best procedure 60-70 WL dumping syndrome malnutrition

bull LAGB- low complications varying range of wt loss frequent post-op visits ( 10)

bull DSBPD- more wt loss high complications good for high BMI gt 50 malabsorption +

bull VBG(vertical band gastroplasty) ndash longest available results good wt loss improved co-morbidities right for some ptsrisks too high to justify rewards

bull SG- needs long term research 1st step procedure low risks higher wt loss lesser complications pouch could Stretch over time long staple line could cause problems in future frequency is accelerating because of technical ease 1st stage procedure before bypass

Post-surgical Complications

Anastomosis leaks or staple line leaks Pulmonary Embolism or DVT Cholelithiasis Stomal ulceration Dumping syndrome Constipation

Anastamosis Leaks

Up to 7-10 days after surgery Most common at gastrojejunostomy enteroenterostomy Roux

limb stump staple line Can lead to peritonitis sepsis possible death Presentation

Tachycardia tachypnea Fever Ab painback pain Pelvic pressure or rebound tenderness

Anastamosis Leaks

Order Gastrograffin upper GI series Subclinical cases

Bowel rest Parenteral nutrition IV antibiotic if H pylori

Clinically suspect leak Laparoscopic evaluation and leak repair

Failure to evaluate is the most common cause of preventable major long-term disability or death in bariatric surgical patients

Pulmonary Embolism

Sudden cause of death up to one month after surgery 20-30 mortality rate High risk may have vena cava filter placement prior to surgery Prophylaxis with compression stockings and LMWH Early ambulation imperitive

Pulmonary Embolism

Presentation Profound hypoxia Hypotension Signs of sepsis

Immediate spiral chest CT Abdominal exploration if too large for machine No pathology start anticoagulation Too largehelliphellipNO SURGERY

Cholelithiasis

Up to 36 of patients within 6 months post-op Bile stasis leads to increased sludge and gallstones Prophylactic cholecystectomy prior to surgery if

evidence of existing sludge or stones Prevent post-operative disease with concurrent bariatric

surgery and cholecystectomy Prophylactic use of urosidol

Expensive and unpalatable

Stomal Ulceration

12-15 within 2-4 mos Post-surgery Etiology

Overabundant acid in pouch leads to excessive acid passing through stoma

Pouch tension and staple line breakdown NSAID use

Presentation Dyspepsia vomiting Epigastric or retrosternal pain

Stomal Ulceration

Treatment PPI carafate Antibiotics if H Pylori Avoid NSAIDS alcohol smoking

If no response to treatment Endoscopy Back to surgery for pouch revision or staple line repair

Dumping Syndrome

More than 15 patients Hypotention Tachycardia Lightheadedness syncope Flushing Abdominal cramping and diarrhea Nausea and vomiting

Dumping Syndrome

Occurs with high dose simple sugar ingestion Sugar in small intestine causes osmotic overload and fluid

shift from blood to intestine Increased intestinal volume leads to watery diarrhea Decreased blood volume leads to systemic changes Patient education

Eat slowly Avoid drinking before during and not until 30 minutes after meals

Constipation

Most common complaint Causes

Dehydration and decreased fluid intake post-operatively Increased metabolic water needs Calcium and iron supplement use following surgery

Treat with increased fluids and stool softeners

Nutritional Consequences

Iron deficiency anemia B12 deficiency Folate deficiency Calcium and Vitamin D deficiency

Not seen with purely restrictive surgeries

Iron deficiency and anemia

Common following RYGB As high as 49 of patients Multifactorial cause

Low gastric acid levels prohibit iron cleavage from food Absorption inhibited because no nutrient exposure to duodenum or

proximal jejunum Decrease in iron-rich food consumption due to intolerance

Treat with oral supplementation of ferrous sulfate or ferrous gluconate

Vitamin B12 deficiency

Up to 70 of patients Lack of hydrochloric acid and pepsin in stomach

Prevents B12 cleavage from food Affects secretion of intrinsic factor thus B12 absorption

Intolerance to meat and milk Oral supplementation usually adequate otherwise IM injections used

Folate Deficiency

40 of gastric bypass patients Complete absorption requires B12 Absorption dependent on HCl and upper 13 stomach Deficiency generally caused by decreased consumption Oral supplementation

Vitamin D and Calcium Deficiency

Vitamin D deficiency is common among obese people Calcium absorption decreased because duodenum is

bypassed Intolerance to dairy foods high in calcium Vitamin D is required for Ca++ absorption Prolonged deficiencies lead to

Bone resorption osteomalacia osteoporosis Treat with calcium citrate supplementation and 2 weekly

doses of Vitamin D

Nutritional Implications of Various Bariatric Surgeries(34)

bull RYGB Malabsorption of Vit B12 Vit B1 (thiamin) Vit D Vit K Folate Iron Calcium

bull LAGB Folic Acid deficiency

bull BPD and BPDDS Vit A D E and K deficiency Protein-Calorie Malnutrition Malabsorption of

Calcium Zinc Selenium Sodium Potassium Chloride Phosphorus Magnesium

Recommended Daily Supplements(4)

Multivitamin with iron (prenatal vitamin will have adeq amount of folic acid)

Calcium (citrate) with vitamin D (1200-1500 mg calcium with 800-1000 IU vitamin D)

Oral vitamin B12 (500-1000 mcg) Iron (65 mgday in elemental form)

Vitamin C (to increase absorption of Iron) Thiamin (10 mgday)

Diet Recommendations(3)

Reduce food volume Chew food very well Slow pace of eating No liquids with meals Encourage fruits and vegetables as diet progresses Include high protein foods (at least 60gday) may need protein

supplements

Diet Progression Gastric Bypass

Stage 1 Clear liquids and protein supplement (1 week)

Stage 2No concentrated sweets low fat puree diet ( 3 weeks)

Stage 3 Regular texture weight reduction diet

Diet Progression Lap - Band

Stage 1 Clear liquids and protein supplement ( 2 weeks)

Stage 2 No concentrated sweets low fat puree diet (2weeks)

Stage 3 Regular texture weight reduction diet

Stage 1

Only clear liquids allowed Avoid sweetened beverages Sip very slowly No straws Avoid caffeinated carbonated and alcoholic beverages STOP drinking if you feel fullness pain or discomfort

Protein supplements

Begin the day after you go home from Hospital

Minimum protein target 70gmsday

May use powder or pre-mixed liquid forms (Whey protein is preferred)

Protein pills may not be used

Vitamin and Mineral Supplements

Gastric bypass patients In addition to eating much less food gastric bypass patients will also

absorb vitamins and minerals differently after surgery They will require daily multivitamin calcium and iron

supplementation for the rest of your life

Vitamin and Mineral Supplements

Lap-Bandreg patients

Require a multivitamin with minerals daily

It may be necessary to take additional vitamins and minerals eg calcium iron folateB1 B12These will be prescribed as needed

Stage 2 dietPUREE

Puree diet

Regular scheduled meals Avoid meal skipping Plan meals in advance Eat Slowly Eat protein foods first Moisten meats Use liquid protein as supplement not as meal replacement

Measure 2 oz portions at each meal eating when full Separate liquids and solids No bread rice or pasta Avoid added sugars and high fat

foods VARIETY

GASTRIC BYPASS LGB

bull The small intestine (the jejunum) is divided using a surgical staplerApprox 50-70 cm from the DJ Junction

GASTRIC BYPASS LGB

Y- LIMB BP LIMB

bull The end of the Roux limb is then attached to the newly formed stomach pouch which carries food to the distal intestine

bull The Roux loop is completed by forming a jejunostomy

bull The Y limb or BPD limb carries digestive juices from the pancreas gall bladder liver and duodenum to the intestines

bull The food and the digestive juices mix where the Roux limb and Y limb meet much below say 100-150 cm from DJ

Roux limb or alimentary limb

100-150 cm

How Does the Roux-en-Y Work

Surgery factors restriction of meal size ldquodumping syndromerdquo some malabsorption decreased appetite

Patient factors calorie intake calorie expenditure

bull Most commonly performedbull Most reliable operation for long term weight lossbull Long term weight loss averages 60 to 75 percent of EBWbull Malnutrition is unusualbull Substantial improvement amp resolution in many co-morbid

obesity conditions

ADVANTAGES OF RYGBP

1 Not reversible

2 Mortality 05- 1

3 Perioperative complications 5-10

4 Stricture of gastrojejunostomy-10 (long term)

5 Long term risk of protein amp vitamin deficiency and marginal ulceration of GJA

6Long term risk of intestinal obstruction ndash 2

LAPAROSCOPIC GASTRIC BYPASSCOMPLICATIONS

Biliopancreatic Diversion (BPD)

Primarily malabsorptive but restrictive component also

First Terminal ileum is measured to a length of 50 cms marked with suture

The alimentary tract beyond the proximal part of stomach is rearranged to

include only distal 200 cm of ileum including common channel

Common channel-Distal 50 cm of terminal ileum for absorption of fat and

protein

The proximal end of ileum anastomosed to proximal end of stomach after

performing distal hemigastrectomy

Biliopancreatic Diversion with Duodenal Switch

Modification to lessen high incidence of vit b12 deficiency anastomotic stricture at gastrojejunal anastomosis

This procedure involves a sleeve gastrectomy that is then diverted at the duodenum into the ileum at a point measured proximally from the ileocecal valve (usually 250 cm)

The distal duodenum and jejunum the biliopancreatic limb are then anastomosed to the ileum at a point measured proximally from the ileocecal valve (usually 100 cm)

Common channel is 100cm Entire alimentary tract is 250 cm This is the most aggressive bypass procedure commonly offered today Major difference-Sleeve gastrectomy instead of distal hemigastrectomy

bull Most women regained normal menstrual function and most had documented

spontaneous ovulation

bull Significant improvement in hirsutism androgen profiles and about a 50 reduction in

HOMA-IR

bull Follow up for more than 2 years showed that all women resumed normal menstrual

cycles HbA1C decreased from 82 to 51 in lt 3 months

bull 78 saw improvement in metabolic syndrome amp 48 showed improvement in PCOS

2 ROLE OF BARIATRIC SURGERY IN PCOS PATIENTS

bull Decrease menstrual irregularities bull PCOS women have less hyper androgenism

bull Sex hormone binding globulin increases bull LH and FSH levels have been reported to increase

bull Ovulatory function measured by luteal LH and Progesterone secretion improved bull Leptin levels decrease reflecting improved reproductive metabolic status

bull Subclinical hypothyroidism significantly reduced

THE SAFE TIMING OF PREGNANCYoptimal or minimal time gt12 months after bariatric surgery before becoming pregnant in order to allow the rapid weight loss and metabolic changes to subside

4 BARIATRIC SURGERY IN REPRODUCTIVE WOMEN

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)

The foregut hypothesis theory ndash 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

Effect of Bariatric Surgery on Diabetes Mellitus

Combined Gastric Restriction amp Malabsorption

Operative Risks (vs cholecystectomy)

Perioperative Mortality 1-2 vs 02-08 Early Complications 10 vs 29Late Complications 20 vs 1-2

LimitationsWidening of (unbanded) gastrojejunostomyExpansion of gastric pouch 25 with nearly 100 weight regainAdaptation of limb that receives the food

SUMMARY OF ALL TYPES OF SURGERY

bull LRYGBP ndash worlds best procedure 60-70 WL dumping syndrome malnutrition

bull LAGB- low complications varying range of wt loss frequent post-op visits ( 10)

bull DSBPD- more wt loss high complications good for high BMI gt 50 malabsorption +

bull VBG(vertical band gastroplasty) ndash longest available results good wt loss improved co-morbidities right for some ptsrisks too high to justify rewards

bull SG- needs long term research 1st step procedure low risks higher wt loss lesser complications pouch could Stretch over time long staple line could cause problems in future frequency is accelerating because of technical ease 1st stage procedure before bypass

Post-surgical Complications

Anastomosis leaks or staple line leaks Pulmonary Embolism or DVT Cholelithiasis Stomal ulceration Dumping syndrome Constipation

Anastamosis Leaks

Up to 7-10 days after surgery Most common at gastrojejunostomy enteroenterostomy Roux

limb stump staple line Can lead to peritonitis sepsis possible death Presentation

Tachycardia tachypnea Fever Ab painback pain Pelvic pressure or rebound tenderness

Anastamosis Leaks

Order Gastrograffin upper GI series Subclinical cases

Bowel rest Parenteral nutrition IV antibiotic if H pylori

Clinically suspect leak Laparoscopic evaluation and leak repair

Failure to evaluate is the most common cause of preventable major long-term disability or death in bariatric surgical patients

Pulmonary Embolism

Sudden cause of death up to one month after surgery 20-30 mortality rate High risk may have vena cava filter placement prior to surgery Prophylaxis with compression stockings and LMWH Early ambulation imperitive

Pulmonary Embolism

Presentation Profound hypoxia Hypotension Signs of sepsis

Immediate spiral chest CT Abdominal exploration if too large for machine No pathology start anticoagulation Too largehelliphellipNO SURGERY

Cholelithiasis

Up to 36 of patients within 6 months post-op Bile stasis leads to increased sludge and gallstones Prophylactic cholecystectomy prior to surgery if

evidence of existing sludge or stones Prevent post-operative disease with concurrent bariatric

surgery and cholecystectomy Prophylactic use of urosidol

Expensive and unpalatable

Stomal Ulceration

12-15 within 2-4 mos Post-surgery Etiology

Overabundant acid in pouch leads to excessive acid passing through stoma

Pouch tension and staple line breakdown NSAID use

Presentation Dyspepsia vomiting Epigastric or retrosternal pain

Stomal Ulceration

Treatment PPI carafate Antibiotics if H Pylori Avoid NSAIDS alcohol smoking

If no response to treatment Endoscopy Back to surgery for pouch revision or staple line repair

Dumping Syndrome

More than 15 patients Hypotention Tachycardia Lightheadedness syncope Flushing Abdominal cramping and diarrhea Nausea and vomiting

Dumping Syndrome

Occurs with high dose simple sugar ingestion Sugar in small intestine causes osmotic overload and fluid

shift from blood to intestine Increased intestinal volume leads to watery diarrhea Decreased blood volume leads to systemic changes Patient education

Eat slowly Avoid drinking before during and not until 30 minutes after meals

Constipation

Most common complaint Causes

Dehydration and decreased fluid intake post-operatively Increased metabolic water needs Calcium and iron supplement use following surgery

Treat with increased fluids and stool softeners

Nutritional Consequences

Iron deficiency anemia B12 deficiency Folate deficiency Calcium and Vitamin D deficiency

Not seen with purely restrictive surgeries

Iron deficiency and anemia

Common following RYGB As high as 49 of patients Multifactorial cause

Low gastric acid levels prohibit iron cleavage from food Absorption inhibited because no nutrient exposure to duodenum or

proximal jejunum Decrease in iron-rich food consumption due to intolerance

Treat with oral supplementation of ferrous sulfate or ferrous gluconate

Vitamin B12 deficiency

Up to 70 of patients Lack of hydrochloric acid and pepsin in stomach

Prevents B12 cleavage from food Affects secretion of intrinsic factor thus B12 absorption

Intolerance to meat and milk Oral supplementation usually adequate otherwise IM injections used

Folate Deficiency

40 of gastric bypass patients Complete absorption requires B12 Absorption dependent on HCl and upper 13 stomach Deficiency generally caused by decreased consumption Oral supplementation

Vitamin D and Calcium Deficiency

Vitamin D deficiency is common among obese people Calcium absorption decreased because duodenum is

bypassed Intolerance to dairy foods high in calcium Vitamin D is required for Ca++ absorption Prolonged deficiencies lead to

Bone resorption osteomalacia osteoporosis Treat with calcium citrate supplementation and 2 weekly

doses of Vitamin D

Nutritional Implications of Various Bariatric Surgeries(34)

bull RYGB Malabsorption of Vit B12 Vit B1 (thiamin) Vit D Vit K Folate Iron Calcium

bull LAGB Folic Acid deficiency

bull BPD and BPDDS Vit A D E and K deficiency Protein-Calorie Malnutrition Malabsorption of

Calcium Zinc Selenium Sodium Potassium Chloride Phosphorus Magnesium

Recommended Daily Supplements(4)

Multivitamin with iron (prenatal vitamin will have adeq amount of folic acid)

Calcium (citrate) with vitamin D (1200-1500 mg calcium with 800-1000 IU vitamin D)

Oral vitamin B12 (500-1000 mcg) Iron (65 mgday in elemental form)

Vitamin C (to increase absorption of Iron) Thiamin (10 mgday)

Diet Recommendations(3)

Reduce food volume Chew food very well Slow pace of eating No liquids with meals Encourage fruits and vegetables as diet progresses Include high protein foods (at least 60gday) may need protein

supplements

Diet Progression Gastric Bypass

Stage 1 Clear liquids and protein supplement (1 week)

Stage 2No concentrated sweets low fat puree diet ( 3 weeks)

Stage 3 Regular texture weight reduction diet

Diet Progression Lap - Band

Stage 1 Clear liquids and protein supplement ( 2 weeks)

Stage 2 No concentrated sweets low fat puree diet (2weeks)

Stage 3 Regular texture weight reduction diet

Stage 1

Only clear liquids allowed Avoid sweetened beverages Sip very slowly No straws Avoid caffeinated carbonated and alcoholic beverages STOP drinking if you feel fullness pain or discomfort

Protein supplements

Begin the day after you go home from Hospital

Minimum protein target 70gmsday

May use powder or pre-mixed liquid forms (Whey protein is preferred)

Protein pills may not be used

Vitamin and Mineral Supplements

Gastric bypass patients In addition to eating much less food gastric bypass patients will also

absorb vitamins and minerals differently after surgery They will require daily multivitamin calcium and iron

supplementation for the rest of your life

Vitamin and Mineral Supplements

Lap-Bandreg patients

Require a multivitamin with minerals daily

It may be necessary to take additional vitamins and minerals eg calcium iron folateB1 B12These will be prescribed as needed

Stage 2 dietPUREE

Puree diet

Regular scheduled meals Avoid meal skipping Plan meals in advance Eat Slowly Eat protein foods first Moisten meats Use liquid protein as supplement not as meal replacement

Measure 2 oz portions at each meal eating when full Separate liquids and solids No bread rice or pasta Avoid added sugars and high fat

foods VARIETY

GASTRIC BYPASS LGB

Y- LIMB BP LIMB

bull The end of the Roux limb is then attached to the newly formed stomach pouch which carries food to the distal intestine

bull The Roux loop is completed by forming a jejunostomy

bull The Y limb or BPD limb carries digestive juices from the pancreas gall bladder liver and duodenum to the intestines

bull The food and the digestive juices mix where the Roux limb and Y limb meet much below say 100-150 cm from DJ

Roux limb or alimentary limb

100-150 cm

How Does the Roux-en-Y Work

Surgery factors restriction of meal size ldquodumping syndromerdquo some malabsorption decreased appetite

Patient factors calorie intake calorie expenditure

bull Most commonly performedbull Most reliable operation for long term weight lossbull Long term weight loss averages 60 to 75 percent of EBWbull Malnutrition is unusualbull Substantial improvement amp resolution in many co-morbid

obesity conditions

ADVANTAGES OF RYGBP

1 Not reversible

2 Mortality 05- 1

3 Perioperative complications 5-10

4 Stricture of gastrojejunostomy-10 (long term)

5 Long term risk of protein amp vitamin deficiency and marginal ulceration of GJA

6Long term risk of intestinal obstruction ndash 2

LAPAROSCOPIC GASTRIC BYPASSCOMPLICATIONS

Biliopancreatic Diversion (BPD)

Primarily malabsorptive but restrictive component also

First Terminal ileum is measured to a length of 50 cms marked with suture

The alimentary tract beyond the proximal part of stomach is rearranged to

include only distal 200 cm of ileum including common channel

Common channel-Distal 50 cm of terminal ileum for absorption of fat and

protein

The proximal end of ileum anastomosed to proximal end of stomach after

performing distal hemigastrectomy

Biliopancreatic Diversion with Duodenal Switch

Modification to lessen high incidence of vit b12 deficiency anastomotic stricture at gastrojejunal anastomosis

This procedure involves a sleeve gastrectomy that is then diverted at the duodenum into the ileum at a point measured proximally from the ileocecal valve (usually 250 cm)

The distal duodenum and jejunum the biliopancreatic limb are then anastomosed to the ileum at a point measured proximally from the ileocecal valve (usually 100 cm)

Common channel is 100cm Entire alimentary tract is 250 cm This is the most aggressive bypass procedure commonly offered today Major difference-Sleeve gastrectomy instead of distal hemigastrectomy

bull Most women regained normal menstrual function and most had documented

spontaneous ovulation

bull Significant improvement in hirsutism androgen profiles and about a 50 reduction in

HOMA-IR

bull Follow up for more than 2 years showed that all women resumed normal menstrual

cycles HbA1C decreased from 82 to 51 in lt 3 months

bull 78 saw improvement in metabolic syndrome amp 48 showed improvement in PCOS

2 ROLE OF BARIATRIC SURGERY IN PCOS PATIENTS

bull Decrease menstrual irregularities bull PCOS women have less hyper androgenism

bull Sex hormone binding globulin increases bull LH and FSH levels have been reported to increase

bull Ovulatory function measured by luteal LH and Progesterone secretion improved bull Leptin levels decrease reflecting improved reproductive metabolic status

bull Subclinical hypothyroidism significantly reduced

THE SAFE TIMING OF PREGNANCYoptimal or minimal time gt12 months after bariatric surgery before becoming pregnant in order to allow the rapid weight loss and metabolic changes to subside

4 BARIATRIC SURGERY IN REPRODUCTIVE WOMEN

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)

The foregut hypothesis theory ndash 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

Effect of Bariatric Surgery on Diabetes Mellitus

Combined Gastric Restriction amp Malabsorption

Operative Risks (vs cholecystectomy)

Perioperative Mortality 1-2 vs 02-08 Early Complications 10 vs 29Late Complications 20 vs 1-2

LimitationsWidening of (unbanded) gastrojejunostomyExpansion of gastric pouch 25 with nearly 100 weight regainAdaptation of limb that receives the food

SUMMARY OF ALL TYPES OF SURGERY

bull LRYGBP ndash worlds best procedure 60-70 WL dumping syndrome malnutrition

bull LAGB- low complications varying range of wt loss frequent post-op visits ( 10)

bull DSBPD- more wt loss high complications good for high BMI gt 50 malabsorption +

bull VBG(vertical band gastroplasty) ndash longest available results good wt loss improved co-morbidities right for some ptsrisks too high to justify rewards

bull SG- needs long term research 1st step procedure low risks higher wt loss lesser complications pouch could Stretch over time long staple line could cause problems in future frequency is accelerating because of technical ease 1st stage procedure before bypass

Post-surgical Complications

Anastomosis leaks or staple line leaks Pulmonary Embolism or DVT Cholelithiasis Stomal ulceration Dumping syndrome Constipation

Anastamosis Leaks

Up to 7-10 days after surgery Most common at gastrojejunostomy enteroenterostomy Roux

limb stump staple line Can lead to peritonitis sepsis possible death Presentation

Tachycardia tachypnea Fever Ab painback pain Pelvic pressure or rebound tenderness

Anastamosis Leaks

Order Gastrograffin upper GI series Subclinical cases

Bowel rest Parenteral nutrition IV antibiotic if H pylori

Clinically suspect leak Laparoscopic evaluation and leak repair

Failure to evaluate is the most common cause of preventable major long-term disability or death in bariatric surgical patients

Pulmonary Embolism

Sudden cause of death up to one month after surgery 20-30 mortality rate High risk may have vena cava filter placement prior to surgery Prophylaxis with compression stockings and LMWH Early ambulation imperitive

Pulmonary Embolism

Presentation Profound hypoxia Hypotension Signs of sepsis

Immediate spiral chest CT Abdominal exploration if too large for machine No pathology start anticoagulation Too largehelliphellipNO SURGERY

Cholelithiasis

Up to 36 of patients within 6 months post-op Bile stasis leads to increased sludge and gallstones Prophylactic cholecystectomy prior to surgery if

evidence of existing sludge or stones Prevent post-operative disease with concurrent bariatric

surgery and cholecystectomy Prophylactic use of urosidol

Expensive and unpalatable

Stomal Ulceration

12-15 within 2-4 mos Post-surgery Etiology

Overabundant acid in pouch leads to excessive acid passing through stoma

Pouch tension and staple line breakdown NSAID use

Presentation Dyspepsia vomiting Epigastric or retrosternal pain

Stomal Ulceration

Treatment PPI carafate Antibiotics if H Pylori Avoid NSAIDS alcohol smoking

If no response to treatment Endoscopy Back to surgery for pouch revision or staple line repair

Dumping Syndrome

More than 15 patients Hypotention Tachycardia Lightheadedness syncope Flushing Abdominal cramping and diarrhea Nausea and vomiting

Dumping Syndrome

Occurs with high dose simple sugar ingestion Sugar in small intestine causes osmotic overload and fluid

shift from blood to intestine Increased intestinal volume leads to watery diarrhea Decreased blood volume leads to systemic changes Patient education

Eat slowly Avoid drinking before during and not until 30 minutes after meals

Constipation

Most common complaint Causes

Dehydration and decreased fluid intake post-operatively Increased metabolic water needs Calcium and iron supplement use following surgery

Treat with increased fluids and stool softeners

Nutritional Consequences

Iron deficiency anemia B12 deficiency Folate deficiency Calcium and Vitamin D deficiency

Not seen with purely restrictive surgeries

Iron deficiency and anemia

Common following RYGB As high as 49 of patients Multifactorial cause

Low gastric acid levels prohibit iron cleavage from food Absorption inhibited because no nutrient exposure to duodenum or

proximal jejunum Decrease in iron-rich food consumption due to intolerance

Treat with oral supplementation of ferrous sulfate or ferrous gluconate

Vitamin B12 deficiency

Up to 70 of patients Lack of hydrochloric acid and pepsin in stomach

Prevents B12 cleavage from food Affects secretion of intrinsic factor thus B12 absorption

Intolerance to meat and milk Oral supplementation usually adequate otherwise IM injections used

Folate Deficiency

40 of gastric bypass patients Complete absorption requires B12 Absorption dependent on HCl and upper 13 stomach Deficiency generally caused by decreased consumption Oral supplementation

Vitamin D and Calcium Deficiency

Vitamin D deficiency is common among obese people Calcium absorption decreased because duodenum is

bypassed Intolerance to dairy foods high in calcium Vitamin D is required for Ca++ absorption Prolonged deficiencies lead to

Bone resorption osteomalacia osteoporosis Treat with calcium citrate supplementation and 2 weekly

doses of Vitamin D

Nutritional Implications of Various Bariatric Surgeries(34)

bull RYGB Malabsorption of Vit B12 Vit B1 (thiamin) Vit D Vit K Folate Iron Calcium

bull LAGB Folic Acid deficiency

bull BPD and BPDDS Vit A D E and K deficiency Protein-Calorie Malnutrition Malabsorption of

Calcium Zinc Selenium Sodium Potassium Chloride Phosphorus Magnesium

Recommended Daily Supplements(4)

Multivitamin with iron (prenatal vitamin will have adeq amount of folic acid)

Calcium (citrate) with vitamin D (1200-1500 mg calcium with 800-1000 IU vitamin D)

Oral vitamin B12 (500-1000 mcg) Iron (65 mgday in elemental form)

Vitamin C (to increase absorption of Iron) Thiamin (10 mgday)

Diet Recommendations(3)

Reduce food volume Chew food very well Slow pace of eating No liquids with meals Encourage fruits and vegetables as diet progresses Include high protein foods (at least 60gday) may need protein

supplements

Diet Progression Gastric Bypass

Stage 1 Clear liquids and protein supplement (1 week)

Stage 2No concentrated sweets low fat puree diet ( 3 weeks)

Stage 3 Regular texture weight reduction diet

Diet Progression Lap - Band

Stage 1 Clear liquids and protein supplement ( 2 weeks)

Stage 2 No concentrated sweets low fat puree diet (2weeks)

Stage 3 Regular texture weight reduction diet

Stage 1

Only clear liquids allowed Avoid sweetened beverages Sip very slowly No straws Avoid caffeinated carbonated and alcoholic beverages STOP drinking if you feel fullness pain or discomfort

Protein supplements

Begin the day after you go home from Hospital

Minimum protein target 70gmsday

May use powder or pre-mixed liquid forms (Whey protein is preferred)

Protein pills may not be used

Vitamin and Mineral Supplements

Gastric bypass patients In addition to eating much less food gastric bypass patients will also

absorb vitamins and minerals differently after surgery They will require daily multivitamin calcium and iron

supplementation for the rest of your life

Vitamin and Mineral Supplements

Lap-Bandreg patients

Require a multivitamin with minerals daily

It may be necessary to take additional vitamins and minerals eg calcium iron folateB1 B12These will be prescribed as needed

Stage 2 dietPUREE

Puree diet

Regular scheduled meals Avoid meal skipping Plan meals in advance Eat Slowly Eat protein foods first Moisten meats Use liquid protein as supplement not as meal replacement

Measure 2 oz portions at each meal eating when full Separate liquids and solids No bread rice or pasta Avoid added sugars and high fat

foods VARIETY

How Does the Roux-en-Y Work

Surgery factors restriction of meal size ldquodumping syndromerdquo some malabsorption decreased appetite

Patient factors calorie intake calorie expenditure

bull Most commonly performedbull Most reliable operation for long term weight lossbull Long term weight loss averages 60 to 75 percent of EBWbull Malnutrition is unusualbull Substantial improvement amp resolution in many co-morbid

obesity conditions

ADVANTAGES OF RYGBP

1 Not reversible

2 Mortality 05- 1

3 Perioperative complications 5-10

4 Stricture of gastrojejunostomy-10 (long term)

5 Long term risk of protein amp vitamin deficiency and marginal ulceration of GJA

6Long term risk of intestinal obstruction ndash 2

LAPAROSCOPIC GASTRIC BYPASSCOMPLICATIONS

Biliopancreatic Diversion (BPD)

Primarily malabsorptive but restrictive component also

First Terminal ileum is measured to a length of 50 cms marked with suture

The alimentary tract beyond the proximal part of stomach is rearranged to

include only distal 200 cm of ileum including common channel

Common channel-Distal 50 cm of terminal ileum for absorption of fat and

protein

The proximal end of ileum anastomosed to proximal end of stomach after

performing distal hemigastrectomy

Biliopancreatic Diversion with Duodenal Switch

Modification to lessen high incidence of vit b12 deficiency anastomotic stricture at gastrojejunal anastomosis

This procedure involves a sleeve gastrectomy that is then diverted at the duodenum into the ileum at a point measured proximally from the ileocecal valve (usually 250 cm)

The distal duodenum and jejunum the biliopancreatic limb are then anastomosed to the ileum at a point measured proximally from the ileocecal valve (usually 100 cm)

Common channel is 100cm Entire alimentary tract is 250 cm This is the most aggressive bypass procedure commonly offered today Major difference-Sleeve gastrectomy instead of distal hemigastrectomy

bull Most women regained normal menstrual function and most had documented

spontaneous ovulation

bull Significant improvement in hirsutism androgen profiles and about a 50 reduction in

HOMA-IR

bull Follow up for more than 2 years showed that all women resumed normal menstrual

cycles HbA1C decreased from 82 to 51 in lt 3 months

bull 78 saw improvement in metabolic syndrome amp 48 showed improvement in PCOS

2 ROLE OF BARIATRIC SURGERY IN PCOS PATIENTS

bull Decrease menstrual irregularities bull PCOS women have less hyper androgenism

bull Sex hormone binding globulin increases bull LH and FSH levels have been reported to increase

bull Ovulatory function measured by luteal LH and Progesterone secretion improved bull Leptin levels decrease reflecting improved reproductive metabolic status

bull Subclinical hypothyroidism significantly reduced

THE SAFE TIMING OF PREGNANCYoptimal or minimal time gt12 months after bariatric surgery before becoming pregnant in order to allow the rapid weight loss and metabolic changes to subside

4 BARIATRIC SURGERY IN REPRODUCTIVE WOMEN

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)

The foregut hypothesis theory ndash 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

Effect of Bariatric Surgery on Diabetes Mellitus

Combined Gastric Restriction amp Malabsorption

Operative Risks (vs cholecystectomy)

Perioperative Mortality 1-2 vs 02-08 Early Complications 10 vs 29Late Complications 20 vs 1-2

LimitationsWidening of (unbanded) gastrojejunostomyExpansion of gastric pouch 25 with nearly 100 weight regainAdaptation of limb that receives the food

SUMMARY OF ALL TYPES OF SURGERY

bull LRYGBP ndash worlds best procedure 60-70 WL dumping syndrome malnutrition

bull LAGB- low complications varying range of wt loss frequent post-op visits ( 10)

bull DSBPD- more wt loss high complications good for high BMI gt 50 malabsorption +

bull VBG(vertical band gastroplasty) ndash longest available results good wt loss improved co-morbidities right for some ptsrisks too high to justify rewards

bull SG- needs long term research 1st step procedure low risks higher wt loss lesser complications pouch could Stretch over time long staple line could cause problems in future frequency is accelerating because of technical ease 1st stage procedure before bypass

Post-surgical Complications

Anastomosis leaks or staple line leaks Pulmonary Embolism or DVT Cholelithiasis Stomal ulceration Dumping syndrome Constipation

Anastamosis Leaks

Up to 7-10 days after surgery Most common at gastrojejunostomy enteroenterostomy Roux

limb stump staple line Can lead to peritonitis sepsis possible death Presentation

Tachycardia tachypnea Fever Ab painback pain Pelvic pressure or rebound tenderness

Anastamosis Leaks

Order Gastrograffin upper GI series Subclinical cases

Bowel rest Parenteral nutrition IV antibiotic if H pylori

Clinically suspect leak Laparoscopic evaluation and leak repair

Failure to evaluate is the most common cause of preventable major long-term disability or death in bariatric surgical patients

Pulmonary Embolism

Sudden cause of death up to one month after surgery 20-30 mortality rate High risk may have vena cava filter placement prior to surgery Prophylaxis with compression stockings and LMWH Early ambulation imperitive

Pulmonary Embolism

Presentation Profound hypoxia Hypotension Signs of sepsis

Immediate spiral chest CT Abdominal exploration if too large for machine No pathology start anticoagulation Too largehelliphellipNO SURGERY

Cholelithiasis

Up to 36 of patients within 6 months post-op Bile stasis leads to increased sludge and gallstones Prophylactic cholecystectomy prior to surgery if

evidence of existing sludge or stones Prevent post-operative disease with concurrent bariatric

surgery and cholecystectomy Prophylactic use of urosidol

Expensive and unpalatable

Stomal Ulceration

12-15 within 2-4 mos Post-surgery Etiology

Overabundant acid in pouch leads to excessive acid passing through stoma

Pouch tension and staple line breakdown NSAID use

Presentation Dyspepsia vomiting Epigastric or retrosternal pain

Stomal Ulceration

Treatment PPI carafate Antibiotics if H Pylori Avoid NSAIDS alcohol smoking

If no response to treatment Endoscopy Back to surgery for pouch revision or staple line repair

Dumping Syndrome

More than 15 patients Hypotention Tachycardia Lightheadedness syncope Flushing Abdominal cramping and diarrhea Nausea and vomiting

Dumping Syndrome

Occurs with high dose simple sugar ingestion Sugar in small intestine causes osmotic overload and fluid

shift from blood to intestine Increased intestinal volume leads to watery diarrhea Decreased blood volume leads to systemic changes Patient education

Eat slowly Avoid drinking before during and not until 30 minutes after meals

Constipation

Most common complaint Causes

Dehydration and decreased fluid intake post-operatively Increased metabolic water needs Calcium and iron supplement use following surgery

Treat with increased fluids and stool softeners

Nutritional Consequences

Iron deficiency anemia B12 deficiency Folate deficiency Calcium and Vitamin D deficiency

Not seen with purely restrictive surgeries

Iron deficiency and anemia

Common following RYGB As high as 49 of patients Multifactorial cause

Low gastric acid levels prohibit iron cleavage from food Absorption inhibited because no nutrient exposure to duodenum or

proximal jejunum Decrease in iron-rich food consumption due to intolerance

Treat with oral supplementation of ferrous sulfate or ferrous gluconate

Vitamin B12 deficiency

Up to 70 of patients Lack of hydrochloric acid and pepsin in stomach

Prevents B12 cleavage from food Affects secretion of intrinsic factor thus B12 absorption

Intolerance to meat and milk Oral supplementation usually adequate otherwise IM injections used

Folate Deficiency

40 of gastric bypass patients Complete absorption requires B12 Absorption dependent on HCl and upper 13 stomach Deficiency generally caused by decreased consumption Oral supplementation

Vitamin D and Calcium Deficiency

Vitamin D deficiency is common among obese people Calcium absorption decreased because duodenum is

bypassed Intolerance to dairy foods high in calcium Vitamin D is required for Ca++ absorption Prolonged deficiencies lead to

Bone resorption osteomalacia osteoporosis Treat with calcium citrate supplementation and 2 weekly

doses of Vitamin D

Nutritional Implications of Various Bariatric Surgeries(34)

bull RYGB Malabsorption of Vit B12 Vit B1 (thiamin) Vit D Vit K Folate Iron Calcium

bull LAGB Folic Acid deficiency

bull BPD and BPDDS Vit A D E and K deficiency Protein-Calorie Malnutrition Malabsorption of

Calcium Zinc Selenium Sodium Potassium Chloride Phosphorus Magnesium

Recommended Daily Supplements(4)

Multivitamin with iron (prenatal vitamin will have adeq amount of folic acid)

Calcium (citrate) with vitamin D (1200-1500 mg calcium with 800-1000 IU vitamin D)

Oral vitamin B12 (500-1000 mcg) Iron (65 mgday in elemental form)

Vitamin C (to increase absorption of Iron) Thiamin (10 mgday)

Diet Recommendations(3)

Reduce food volume Chew food very well Slow pace of eating No liquids with meals Encourage fruits and vegetables as diet progresses Include high protein foods (at least 60gday) may need protein

supplements

Diet Progression Gastric Bypass

Stage 1 Clear liquids and protein supplement (1 week)

Stage 2No concentrated sweets low fat puree diet ( 3 weeks)

Stage 3 Regular texture weight reduction diet

Diet Progression Lap - Band

Stage 1 Clear liquids and protein supplement ( 2 weeks)

Stage 2 No concentrated sweets low fat puree diet (2weeks)

Stage 3 Regular texture weight reduction diet

Stage 1

Only clear liquids allowed Avoid sweetened beverages Sip very slowly No straws Avoid caffeinated carbonated and alcoholic beverages STOP drinking if you feel fullness pain or discomfort

Protein supplements

Begin the day after you go home from Hospital

Minimum protein target 70gmsday

May use powder or pre-mixed liquid forms (Whey protein is preferred)

Protein pills may not be used

Vitamin and Mineral Supplements

Gastric bypass patients In addition to eating much less food gastric bypass patients will also

absorb vitamins and minerals differently after surgery They will require daily multivitamin calcium and iron

supplementation for the rest of your life

Vitamin and Mineral Supplements

Lap-Bandreg patients

Require a multivitamin with minerals daily

It may be necessary to take additional vitamins and minerals eg calcium iron folateB1 B12These will be prescribed as needed

Stage 2 dietPUREE

Puree diet

Regular scheduled meals Avoid meal skipping Plan meals in advance Eat Slowly Eat protein foods first Moisten meats Use liquid protein as supplement not as meal replacement

Measure 2 oz portions at each meal eating when full Separate liquids and solids No bread rice or pasta Avoid added sugars and high fat

foods VARIETY

bull Most commonly performedbull Most reliable operation for long term weight lossbull Long term weight loss averages 60 to 75 percent of EBWbull Malnutrition is unusualbull Substantial improvement amp resolution in many co-morbid

obesity conditions

ADVANTAGES OF RYGBP

1 Not reversible

2 Mortality 05- 1

3 Perioperative complications 5-10

4 Stricture of gastrojejunostomy-10 (long term)

5 Long term risk of protein amp vitamin deficiency and marginal ulceration of GJA

6Long term risk of intestinal obstruction ndash 2

LAPAROSCOPIC GASTRIC BYPASSCOMPLICATIONS

Biliopancreatic Diversion (BPD)

Primarily malabsorptive but restrictive component also

First Terminal ileum is measured to a length of 50 cms marked with suture

The alimentary tract beyond the proximal part of stomach is rearranged to

include only distal 200 cm of ileum including common channel

Common channel-Distal 50 cm of terminal ileum for absorption of fat and

protein

The proximal end of ileum anastomosed to proximal end of stomach after

performing distal hemigastrectomy

Biliopancreatic Diversion with Duodenal Switch

Modification to lessen high incidence of vit b12 deficiency anastomotic stricture at gastrojejunal anastomosis

This procedure involves a sleeve gastrectomy that is then diverted at the duodenum into the ileum at a point measured proximally from the ileocecal valve (usually 250 cm)

The distal duodenum and jejunum the biliopancreatic limb are then anastomosed to the ileum at a point measured proximally from the ileocecal valve (usually 100 cm)

Common channel is 100cm Entire alimentary tract is 250 cm This is the most aggressive bypass procedure commonly offered today Major difference-Sleeve gastrectomy instead of distal hemigastrectomy

bull Most women regained normal menstrual function and most had documented

spontaneous ovulation

bull Significant improvement in hirsutism androgen profiles and about a 50 reduction in

HOMA-IR

bull Follow up for more than 2 years showed that all women resumed normal menstrual

cycles HbA1C decreased from 82 to 51 in lt 3 months

bull 78 saw improvement in metabolic syndrome amp 48 showed improvement in PCOS

2 ROLE OF BARIATRIC SURGERY IN PCOS PATIENTS

bull Decrease menstrual irregularities bull PCOS women have less hyper androgenism

bull Sex hormone binding globulin increases bull LH and FSH levels have been reported to increase

bull Ovulatory function measured by luteal LH and Progesterone secretion improved bull Leptin levels decrease reflecting improved reproductive metabolic status

bull Subclinical hypothyroidism significantly reduced

THE SAFE TIMING OF PREGNANCYoptimal or minimal time gt12 months after bariatric surgery before becoming pregnant in order to allow the rapid weight loss and metabolic changes to subside

4 BARIATRIC SURGERY IN REPRODUCTIVE WOMEN

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)

The foregut hypothesis theory ndash 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

Effect of Bariatric Surgery on Diabetes Mellitus

Combined Gastric Restriction amp Malabsorption

Operative Risks (vs cholecystectomy)

Perioperative Mortality 1-2 vs 02-08 Early Complications 10 vs 29Late Complications 20 vs 1-2

LimitationsWidening of (unbanded) gastrojejunostomyExpansion of gastric pouch 25 with nearly 100 weight regainAdaptation of limb that receives the food

SUMMARY OF ALL TYPES OF SURGERY

bull LRYGBP ndash worlds best procedure 60-70 WL dumping syndrome malnutrition

bull LAGB- low complications varying range of wt loss frequent post-op visits ( 10)

bull DSBPD- more wt loss high complications good for high BMI gt 50 malabsorption +

bull VBG(vertical band gastroplasty) ndash longest available results good wt loss improved co-morbidities right for some ptsrisks too high to justify rewards

bull SG- needs long term research 1st step procedure low risks higher wt loss lesser complications pouch could Stretch over time long staple line could cause problems in future frequency is accelerating because of technical ease 1st stage procedure before bypass

Post-surgical Complications

Anastomosis leaks or staple line leaks Pulmonary Embolism or DVT Cholelithiasis Stomal ulceration Dumping syndrome Constipation

Anastamosis Leaks

Up to 7-10 days after surgery Most common at gastrojejunostomy enteroenterostomy Roux

limb stump staple line Can lead to peritonitis sepsis possible death Presentation

Tachycardia tachypnea Fever Ab painback pain Pelvic pressure or rebound tenderness

Anastamosis Leaks

Order Gastrograffin upper GI series Subclinical cases

Bowel rest Parenteral nutrition IV antibiotic if H pylori

Clinically suspect leak Laparoscopic evaluation and leak repair

Failure to evaluate is the most common cause of preventable major long-term disability or death in bariatric surgical patients

Pulmonary Embolism

Sudden cause of death up to one month after surgery 20-30 mortality rate High risk may have vena cava filter placement prior to surgery Prophylaxis with compression stockings and LMWH Early ambulation imperitive

Pulmonary Embolism

Presentation Profound hypoxia Hypotension Signs of sepsis

Immediate spiral chest CT Abdominal exploration if too large for machine No pathology start anticoagulation Too largehelliphellipNO SURGERY

Cholelithiasis

Up to 36 of patients within 6 months post-op Bile stasis leads to increased sludge and gallstones Prophylactic cholecystectomy prior to surgery if

evidence of existing sludge or stones Prevent post-operative disease with concurrent bariatric

surgery and cholecystectomy Prophylactic use of urosidol

Expensive and unpalatable

Stomal Ulceration

12-15 within 2-4 mos Post-surgery Etiology

Overabundant acid in pouch leads to excessive acid passing through stoma

Pouch tension and staple line breakdown NSAID use

Presentation Dyspepsia vomiting Epigastric or retrosternal pain

Stomal Ulceration

Treatment PPI carafate Antibiotics if H Pylori Avoid NSAIDS alcohol smoking

If no response to treatment Endoscopy Back to surgery for pouch revision or staple line repair

Dumping Syndrome

More than 15 patients Hypotention Tachycardia Lightheadedness syncope Flushing Abdominal cramping and diarrhea Nausea and vomiting

Dumping Syndrome

Occurs with high dose simple sugar ingestion Sugar in small intestine causes osmotic overload and fluid

shift from blood to intestine Increased intestinal volume leads to watery diarrhea Decreased blood volume leads to systemic changes Patient education

Eat slowly Avoid drinking before during and not until 30 minutes after meals

Constipation

Most common complaint Causes

Dehydration and decreased fluid intake post-operatively Increased metabolic water needs Calcium and iron supplement use following surgery

Treat with increased fluids and stool softeners

Nutritional Consequences

Iron deficiency anemia B12 deficiency Folate deficiency Calcium and Vitamin D deficiency

Not seen with purely restrictive surgeries

Iron deficiency and anemia

Common following RYGB As high as 49 of patients Multifactorial cause

Low gastric acid levels prohibit iron cleavage from food Absorption inhibited because no nutrient exposure to duodenum or

proximal jejunum Decrease in iron-rich food consumption due to intolerance

Treat with oral supplementation of ferrous sulfate or ferrous gluconate

Vitamin B12 deficiency

Up to 70 of patients Lack of hydrochloric acid and pepsin in stomach

Prevents B12 cleavage from food Affects secretion of intrinsic factor thus B12 absorption

Intolerance to meat and milk Oral supplementation usually adequate otherwise IM injections used

Folate Deficiency

40 of gastric bypass patients Complete absorption requires B12 Absorption dependent on HCl and upper 13 stomach Deficiency generally caused by decreased consumption Oral supplementation

Vitamin D and Calcium Deficiency

Vitamin D deficiency is common among obese people Calcium absorption decreased because duodenum is

bypassed Intolerance to dairy foods high in calcium Vitamin D is required for Ca++ absorption Prolonged deficiencies lead to

Bone resorption osteomalacia osteoporosis Treat with calcium citrate supplementation and 2 weekly

doses of Vitamin D

Nutritional Implications of Various Bariatric Surgeries(34)

bull RYGB Malabsorption of Vit B12 Vit B1 (thiamin) Vit D Vit K Folate Iron Calcium

bull LAGB Folic Acid deficiency

bull BPD and BPDDS Vit A D E and K deficiency Protein-Calorie Malnutrition Malabsorption of

Calcium Zinc Selenium Sodium Potassium Chloride Phosphorus Magnesium

Recommended Daily Supplements(4)

Multivitamin with iron (prenatal vitamin will have adeq amount of folic acid)

Calcium (citrate) with vitamin D (1200-1500 mg calcium with 800-1000 IU vitamin D)

Oral vitamin B12 (500-1000 mcg) Iron (65 mgday in elemental form)

Vitamin C (to increase absorption of Iron) Thiamin (10 mgday)

Diet Recommendations(3)

Reduce food volume Chew food very well Slow pace of eating No liquids with meals Encourage fruits and vegetables as diet progresses Include high protein foods (at least 60gday) may need protein

supplements

Diet Progression Gastric Bypass

Stage 1 Clear liquids and protein supplement (1 week)

Stage 2No concentrated sweets low fat puree diet ( 3 weeks)

Stage 3 Regular texture weight reduction diet

Diet Progression Lap - Band

Stage 1 Clear liquids and protein supplement ( 2 weeks)

Stage 2 No concentrated sweets low fat puree diet (2weeks)

Stage 3 Regular texture weight reduction diet

Stage 1

Only clear liquids allowed Avoid sweetened beverages Sip very slowly No straws Avoid caffeinated carbonated and alcoholic beverages STOP drinking if you feel fullness pain or discomfort

Protein supplements

Begin the day after you go home from Hospital

Minimum protein target 70gmsday

May use powder or pre-mixed liquid forms (Whey protein is preferred)

Protein pills may not be used

Vitamin and Mineral Supplements

Gastric bypass patients In addition to eating much less food gastric bypass patients will also

absorb vitamins and minerals differently after surgery They will require daily multivitamin calcium and iron

supplementation for the rest of your life

Vitamin and Mineral Supplements

Lap-Bandreg patients

Require a multivitamin with minerals daily

It may be necessary to take additional vitamins and minerals eg calcium iron folateB1 B12These will be prescribed as needed

Stage 2 dietPUREE

Puree diet

Regular scheduled meals Avoid meal skipping Plan meals in advance Eat Slowly Eat protein foods first Moisten meats Use liquid protein as supplement not as meal replacement

Measure 2 oz portions at each meal eating when full Separate liquids and solids No bread rice or pasta Avoid added sugars and high fat

foods VARIETY

1 Not reversible

2 Mortality 05- 1

3 Perioperative complications 5-10

4 Stricture of gastrojejunostomy-10 (long term)

5 Long term risk of protein amp vitamin deficiency and marginal ulceration of GJA

6Long term risk of intestinal obstruction ndash 2

LAPAROSCOPIC GASTRIC BYPASSCOMPLICATIONS

Biliopancreatic Diversion (BPD)

Primarily malabsorptive but restrictive component also

First Terminal ileum is measured to a length of 50 cms marked with suture

The alimentary tract beyond the proximal part of stomach is rearranged to

include only distal 200 cm of ileum including common channel

Common channel-Distal 50 cm of terminal ileum for absorption of fat and

protein

The proximal end of ileum anastomosed to proximal end of stomach after

performing distal hemigastrectomy

Biliopancreatic Diversion with Duodenal Switch

Modification to lessen high incidence of vit b12 deficiency anastomotic stricture at gastrojejunal anastomosis

This procedure involves a sleeve gastrectomy that is then diverted at the duodenum into the ileum at a point measured proximally from the ileocecal valve (usually 250 cm)

The distal duodenum and jejunum the biliopancreatic limb are then anastomosed to the ileum at a point measured proximally from the ileocecal valve (usually 100 cm)

Common channel is 100cm Entire alimentary tract is 250 cm This is the most aggressive bypass procedure commonly offered today Major difference-Sleeve gastrectomy instead of distal hemigastrectomy

bull Most women regained normal menstrual function and most had documented

spontaneous ovulation

bull Significant improvement in hirsutism androgen profiles and about a 50 reduction in

HOMA-IR

bull Follow up for more than 2 years showed that all women resumed normal menstrual

cycles HbA1C decreased from 82 to 51 in lt 3 months

bull 78 saw improvement in metabolic syndrome amp 48 showed improvement in PCOS

2 ROLE OF BARIATRIC SURGERY IN PCOS PATIENTS

bull Decrease menstrual irregularities bull PCOS women have less hyper androgenism

bull Sex hormone binding globulin increases bull LH and FSH levels have been reported to increase

bull Ovulatory function measured by luteal LH and Progesterone secretion improved bull Leptin levels decrease reflecting improved reproductive metabolic status

bull Subclinical hypothyroidism significantly reduced

THE SAFE TIMING OF PREGNANCYoptimal or minimal time gt12 months after bariatric surgery before becoming pregnant in order to allow the rapid weight loss and metabolic changes to subside

4 BARIATRIC SURGERY IN REPRODUCTIVE WOMEN

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)

The foregut hypothesis theory ndash 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

Effect of Bariatric Surgery on Diabetes Mellitus

Combined Gastric Restriction amp Malabsorption

Operative Risks (vs cholecystectomy)

Perioperative Mortality 1-2 vs 02-08 Early Complications 10 vs 29Late Complications 20 vs 1-2

LimitationsWidening of (unbanded) gastrojejunostomyExpansion of gastric pouch 25 with nearly 100 weight regainAdaptation of limb that receives the food

SUMMARY OF ALL TYPES OF SURGERY

bull LRYGBP ndash worlds best procedure 60-70 WL dumping syndrome malnutrition

bull LAGB- low complications varying range of wt loss frequent post-op visits ( 10)

bull DSBPD- more wt loss high complications good for high BMI gt 50 malabsorption +

bull VBG(vertical band gastroplasty) ndash longest available results good wt loss improved co-morbidities right for some ptsrisks too high to justify rewards

bull SG- needs long term research 1st step procedure low risks higher wt loss lesser complications pouch could Stretch over time long staple line could cause problems in future frequency is accelerating because of technical ease 1st stage procedure before bypass

Post-surgical Complications

Anastomosis leaks or staple line leaks Pulmonary Embolism or DVT Cholelithiasis Stomal ulceration Dumping syndrome Constipation

Anastamosis Leaks

Up to 7-10 days after surgery Most common at gastrojejunostomy enteroenterostomy Roux

limb stump staple line Can lead to peritonitis sepsis possible death Presentation

Tachycardia tachypnea Fever Ab painback pain Pelvic pressure or rebound tenderness

Anastamosis Leaks

Order Gastrograffin upper GI series Subclinical cases

Bowel rest Parenteral nutrition IV antibiotic if H pylori

Clinically suspect leak Laparoscopic evaluation and leak repair

Failure to evaluate is the most common cause of preventable major long-term disability or death in bariatric surgical patients

Pulmonary Embolism

Sudden cause of death up to one month after surgery 20-30 mortality rate High risk may have vena cava filter placement prior to surgery Prophylaxis with compression stockings and LMWH Early ambulation imperitive

Pulmonary Embolism

Presentation Profound hypoxia Hypotension Signs of sepsis

Immediate spiral chest CT Abdominal exploration if too large for machine No pathology start anticoagulation Too largehelliphellipNO SURGERY

Cholelithiasis

Up to 36 of patients within 6 months post-op Bile stasis leads to increased sludge and gallstones Prophylactic cholecystectomy prior to surgery if

evidence of existing sludge or stones Prevent post-operative disease with concurrent bariatric

surgery and cholecystectomy Prophylactic use of urosidol

Expensive and unpalatable

Stomal Ulceration

12-15 within 2-4 mos Post-surgery Etiology

Overabundant acid in pouch leads to excessive acid passing through stoma

Pouch tension and staple line breakdown NSAID use

Presentation Dyspepsia vomiting Epigastric or retrosternal pain

Stomal Ulceration

Treatment PPI carafate Antibiotics if H Pylori Avoid NSAIDS alcohol smoking

If no response to treatment Endoscopy Back to surgery for pouch revision or staple line repair

Dumping Syndrome

More than 15 patients Hypotention Tachycardia Lightheadedness syncope Flushing Abdominal cramping and diarrhea Nausea and vomiting

Dumping Syndrome

Occurs with high dose simple sugar ingestion Sugar in small intestine causes osmotic overload and fluid

shift from blood to intestine Increased intestinal volume leads to watery diarrhea Decreased blood volume leads to systemic changes Patient education

Eat slowly Avoid drinking before during and not until 30 minutes after meals

Constipation

Most common complaint Causes

Dehydration and decreased fluid intake post-operatively Increased metabolic water needs Calcium and iron supplement use following surgery

Treat with increased fluids and stool softeners

Nutritional Consequences

Iron deficiency anemia B12 deficiency Folate deficiency Calcium and Vitamin D deficiency

Not seen with purely restrictive surgeries

Iron deficiency and anemia

Common following RYGB As high as 49 of patients Multifactorial cause

Low gastric acid levels prohibit iron cleavage from food Absorption inhibited because no nutrient exposure to duodenum or

proximal jejunum Decrease in iron-rich food consumption due to intolerance

Treat with oral supplementation of ferrous sulfate or ferrous gluconate

Vitamin B12 deficiency

Up to 70 of patients Lack of hydrochloric acid and pepsin in stomach

Prevents B12 cleavage from food Affects secretion of intrinsic factor thus B12 absorption

Intolerance to meat and milk Oral supplementation usually adequate otherwise IM injections used

Folate Deficiency

40 of gastric bypass patients Complete absorption requires B12 Absorption dependent on HCl and upper 13 stomach Deficiency generally caused by decreased consumption Oral supplementation

Vitamin D and Calcium Deficiency

Vitamin D deficiency is common among obese people Calcium absorption decreased because duodenum is

bypassed Intolerance to dairy foods high in calcium Vitamin D is required for Ca++ absorption Prolonged deficiencies lead to

Bone resorption osteomalacia osteoporosis Treat with calcium citrate supplementation and 2 weekly

doses of Vitamin D

Nutritional Implications of Various Bariatric Surgeries(34)

bull RYGB Malabsorption of Vit B12 Vit B1 (thiamin) Vit D Vit K Folate Iron Calcium

bull LAGB Folic Acid deficiency

bull BPD and BPDDS Vit A D E and K deficiency Protein-Calorie Malnutrition Malabsorption of

Calcium Zinc Selenium Sodium Potassium Chloride Phosphorus Magnesium

Recommended Daily Supplements(4)

Multivitamin with iron (prenatal vitamin will have adeq amount of folic acid)

Calcium (citrate) with vitamin D (1200-1500 mg calcium with 800-1000 IU vitamin D)

Oral vitamin B12 (500-1000 mcg) Iron (65 mgday in elemental form)

Vitamin C (to increase absorption of Iron) Thiamin (10 mgday)

Diet Recommendations(3)

Reduce food volume Chew food very well Slow pace of eating No liquids with meals Encourage fruits and vegetables as diet progresses Include high protein foods (at least 60gday) may need protein

supplements

Diet Progression Gastric Bypass

Stage 1 Clear liquids and protein supplement (1 week)

Stage 2No concentrated sweets low fat puree diet ( 3 weeks)

Stage 3 Regular texture weight reduction diet

Diet Progression Lap - Band

Stage 1 Clear liquids and protein supplement ( 2 weeks)

Stage 2 No concentrated sweets low fat puree diet (2weeks)

Stage 3 Regular texture weight reduction diet

Stage 1

Only clear liquids allowed Avoid sweetened beverages Sip very slowly No straws Avoid caffeinated carbonated and alcoholic beverages STOP drinking if you feel fullness pain or discomfort

Protein supplements

Begin the day after you go home from Hospital

Minimum protein target 70gmsday

May use powder or pre-mixed liquid forms (Whey protein is preferred)

Protein pills may not be used

Vitamin and Mineral Supplements

Gastric bypass patients In addition to eating much less food gastric bypass patients will also

absorb vitamins and minerals differently after surgery They will require daily multivitamin calcium and iron

supplementation for the rest of your life

Vitamin and Mineral Supplements

Lap-Bandreg patients

Require a multivitamin with minerals daily

It may be necessary to take additional vitamins and minerals eg calcium iron folateB1 B12These will be prescribed as needed

Stage 2 dietPUREE

Puree diet

Regular scheduled meals Avoid meal skipping Plan meals in advance Eat Slowly Eat protein foods first Moisten meats Use liquid protein as supplement not as meal replacement

Measure 2 oz portions at each meal eating when full Separate liquids and solids No bread rice or pasta Avoid added sugars and high fat

foods VARIETY

Biliopancreatic Diversion (BPD)

Primarily malabsorptive but restrictive component also

First Terminal ileum is measured to a length of 50 cms marked with suture

The alimentary tract beyond the proximal part of stomach is rearranged to

include only distal 200 cm of ileum including common channel

Common channel-Distal 50 cm of terminal ileum for absorption of fat and

protein

The proximal end of ileum anastomosed to proximal end of stomach after

performing distal hemigastrectomy

Biliopancreatic Diversion with Duodenal Switch

Modification to lessen high incidence of vit b12 deficiency anastomotic stricture at gastrojejunal anastomosis

This procedure involves a sleeve gastrectomy that is then diverted at the duodenum into the ileum at a point measured proximally from the ileocecal valve (usually 250 cm)

The distal duodenum and jejunum the biliopancreatic limb are then anastomosed to the ileum at a point measured proximally from the ileocecal valve (usually 100 cm)

Common channel is 100cm Entire alimentary tract is 250 cm This is the most aggressive bypass procedure commonly offered today Major difference-Sleeve gastrectomy instead of distal hemigastrectomy

bull Most women regained normal menstrual function and most had documented

spontaneous ovulation

bull Significant improvement in hirsutism androgen profiles and about a 50 reduction in

HOMA-IR

bull Follow up for more than 2 years showed that all women resumed normal menstrual

cycles HbA1C decreased from 82 to 51 in lt 3 months

bull 78 saw improvement in metabolic syndrome amp 48 showed improvement in PCOS

2 ROLE OF BARIATRIC SURGERY IN PCOS PATIENTS

bull Decrease menstrual irregularities bull PCOS women have less hyper androgenism

bull Sex hormone binding globulin increases bull LH and FSH levels have been reported to increase

bull Ovulatory function measured by luteal LH and Progesterone secretion improved bull Leptin levels decrease reflecting improved reproductive metabolic status

bull Subclinical hypothyroidism significantly reduced

THE SAFE TIMING OF PREGNANCYoptimal or minimal time gt12 months after bariatric surgery before becoming pregnant in order to allow the rapid weight loss and metabolic changes to subside

4 BARIATRIC SURGERY IN REPRODUCTIVE WOMEN

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)

The foregut hypothesis theory ndash 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

Effect of Bariatric Surgery on Diabetes Mellitus

Combined Gastric Restriction amp Malabsorption

Operative Risks (vs cholecystectomy)

Perioperative Mortality 1-2 vs 02-08 Early Complications 10 vs 29Late Complications 20 vs 1-2

LimitationsWidening of (unbanded) gastrojejunostomyExpansion of gastric pouch 25 with nearly 100 weight regainAdaptation of limb that receives the food

SUMMARY OF ALL TYPES OF SURGERY

bull LRYGBP ndash worlds best procedure 60-70 WL dumping syndrome malnutrition

bull LAGB- low complications varying range of wt loss frequent post-op visits ( 10)

bull DSBPD- more wt loss high complications good for high BMI gt 50 malabsorption +

bull VBG(vertical band gastroplasty) ndash longest available results good wt loss improved co-morbidities right for some ptsrisks too high to justify rewards

bull SG- needs long term research 1st step procedure low risks higher wt loss lesser complications pouch could Stretch over time long staple line could cause problems in future frequency is accelerating because of technical ease 1st stage procedure before bypass

Post-surgical Complications

Anastomosis leaks or staple line leaks Pulmonary Embolism or DVT Cholelithiasis Stomal ulceration Dumping syndrome Constipation

Anastamosis Leaks

Up to 7-10 days after surgery Most common at gastrojejunostomy enteroenterostomy Roux

limb stump staple line Can lead to peritonitis sepsis possible death Presentation

Tachycardia tachypnea Fever Ab painback pain Pelvic pressure or rebound tenderness

Anastamosis Leaks

Order Gastrograffin upper GI series Subclinical cases

Bowel rest Parenteral nutrition IV antibiotic if H pylori

Clinically suspect leak Laparoscopic evaluation and leak repair

Failure to evaluate is the most common cause of preventable major long-term disability or death in bariatric surgical patients

Pulmonary Embolism

Sudden cause of death up to one month after surgery 20-30 mortality rate High risk may have vena cava filter placement prior to surgery Prophylaxis with compression stockings and LMWH Early ambulation imperitive

Pulmonary Embolism

Presentation Profound hypoxia Hypotension Signs of sepsis

Immediate spiral chest CT Abdominal exploration if too large for machine No pathology start anticoagulation Too largehelliphellipNO SURGERY

Cholelithiasis

Up to 36 of patients within 6 months post-op Bile stasis leads to increased sludge and gallstones Prophylactic cholecystectomy prior to surgery if

evidence of existing sludge or stones Prevent post-operative disease with concurrent bariatric

surgery and cholecystectomy Prophylactic use of urosidol

Expensive and unpalatable

Stomal Ulceration

12-15 within 2-4 mos Post-surgery Etiology

Overabundant acid in pouch leads to excessive acid passing through stoma

Pouch tension and staple line breakdown NSAID use

Presentation Dyspepsia vomiting Epigastric or retrosternal pain

Stomal Ulceration

Treatment PPI carafate Antibiotics if H Pylori Avoid NSAIDS alcohol smoking

If no response to treatment Endoscopy Back to surgery for pouch revision or staple line repair

Dumping Syndrome

More than 15 patients Hypotention Tachycardia Lightheadedness syncope Flushing Abdominal cramping and diarrhea Nausea and vomiting

Dumping Syndrome

Occurs with high dose simple sugar ingestion Sugar in small intestine causes osmotic overload and fluid

shift from blood to intestine Increased intestinal volume leads to watery diarrhea Decreased blood volume leads to systemic changes Patient education

Eat slowly Avoid drinking before during and not until 30 minutes after meals

Constipation

Most common complaint Causes

Dehydration and decreased fluid intake post-operatively Increased metabolic water needs Calcium and iron supplement use following surgery

Treat with increased fluids and stool softeners

Nutritional Consequences

Iron deficiency anemia B12 deficiency Folate deficiency Calcium and Vitamin D deficiency

Not seen with purely restrictive surgeries

Iron deficiency and anemia

Common following RYGB As high as 49 of patients Multifactorial cause

Low gastric acid levels prohibit iron cleavage from food Absorption inhibited because no nutrient exposure to duodenum or

proximal jejunum Decrease in iron-rich food consumption due to intolerance

Treat with oral supplementation of ferrous sulfate or ferrous gluconate

Vitamin B12 deficiency

Up to 70 of patients Lack of hydrochloric acid and pepsin in stomach

Prevents B12 cleavage from food Affects secretion of intrinsic factor thus B12 absorption

Intolerance to meat and milk Oral supplementation usually adequate otherwise IM injections used

Folate Deficiency

40 of gastric bypass patients Complete absorption requires B12 Absorption dependent on HCl and upper 13 stomach Deficiency generally caused by decreased consumption Oral supplementation

Vitamin D and Calcium Deficiency

Vitamin D deficiency is common among obese people Calcium absorption decreased because duodenum is

bypassed Intolerance to dairy foods high in calcium Vitamin D is required for Ca++ absorption Prolonged deficiencies lead to

Bone resorption osteomalacia osteoporosis Treat with calcium citrate supplementation and 2 weekly

doses of Vitamin D

Nutritional Implications of Various Bariatric Surgeries(34)

bull RYGB Malabsorption of Vit B12 Vit B1 (thiamin) Vit D Vit K Folate Iron Calcium

bull LAGB Folic Acid deficiency

bull BPD and BPDDS Vit A D E and K deficiency Protein-Calorie Malnutrition Malabsorption of

Calcium Zinc Selenium Sodium Potassium Chloride Phosphorus Magnesium

Recommended Daily Supplements(4)

Multivitamin with iron (prenatal vitamin will have adeq amount of folic acid)

Calcium (citrate) with vitamin D (1200-1500 mg calcium with 800-1000 IU vitamin D)

Oral vitamin B12 (500-1000 mcg) Iron (65 mgday in elemental form)

Vitamin C (to increase absorption of Iron) Thiamin (10 mgday)

Diet Recommendations(3)

Reduce food volume Chew food very well Slow pace of eating No liquids with meals Encourage fruits and vegetables as diet progresses Include high protein foods (at least 60gday) may need protein

supplements

Diet Progression Gastric Bypass

Stage 1 Clear liquids and protein supplement (1 week)

Stage 2No concentrated sweets low fat puree diet ( 3 weeks)

Stage 3 Regular texture weight reduction diet

Diet Progression Lap - Band

Stage 1 Clear liquids and protein supplement ( 2 weeks)

Stage 2 No concentrated sweets low fat puree diet (2weeks)

Stage 3 Regular texture weight reduction diet

Stage 1

Only clear liquids allowed Avoid sweetened beverages Sip very slowly No straws Avoid caffeinated carbonated and alcoholic beverages STOP drinking if you feel fullness pain or discomfort

Protein supplements

Begin the day after you go home from Hospital

Minimum protein target 70gmsday

May use powder or pre-mixed liquid forms (Whey protein is preferred)

Protein pills may not be used

Vitamin and Mineral Supplements

Gastric bypass patients In addition to eating much less food gastric bypass patients will also

absorb vitamins and minerals differently after surgery They will require daily multivitamin calcium and iron

supplementation for the rest of your life

Vitamin and Mineral Supplements

Lap-Bandreg patients

Require a multivitamin with minerals daily

It may be necessary to take additional vitamins and minerals eg calcium iron folateB1 B12These will be prescribed as needed

Stage 2 dietPUREE

Puree diet

Regular scheduled meals Avoid meal skipping Plan meals in advance Eat Slowly Eat protein foods first Moisten meats Use liquid protein as supplement not as meal replacement

Measure 2 oz portions at each meal eating when full Separate liquids and solids No bread rice or pasta Avoid added sugars and high fat

foods VARIETY

Biliopancreatic Diversion with Duodenal Switch

Modification to lessen high incidence of vit b12 deficiency anastomotic stricture at gastrojejunal anastomosis

This procedure involves a sleeve gastrectomy that is then diverted at the duodenum into the ileum at a point measured proximally from the ileocecal valve (usually 250 cm)

The distal duodenum and jejunum the biliopancreatic limb are then anastomosed to the ileum at a point measured proximally from the ileocecal valve (usually 100 cm)

Common channel is 100cm Entire alimentary tract is 250 cm This is the most aggressive bypass procedure commonly offered today Major difference-Sleeve gastrectomy instead of distal hemigastrectomy

bull Most women regained normal menstrual function and most had documented

spontaneous ovulation

bull Significant improvement in hirsutism androgen profiles and about a 50 reduction in

HOMA-IR

bull Follow up for more than 2 years showed that all women resumed normal menstrual

cycles HbA1C decreased from 82 to 51 in lt 3 months

bull 78 saw improvement in metabolic syndrome amp 48 showed improvement in PCOS

2 ROLE OF BARIATRIC SURGERY IN PCOS PATIENTS

bull Decrease menstrual irregularities bull PCOS women have less hyper androgenism

bull Sex hormone binding globulin increases bull LH and FSH levels have been reported to increase

bull Ovulatory function measured by luteal LH and Progesterone secretion improved bull Leptin levels decrease reflecting improved reproductive metabolic status

bull Subclinical hypothyroidism significantly reduced

THE SAFE TIMING OF PREGNANCYoptimal or minimal time gt12 months after bariatric surgery before becoming pregnant in order to allow the rapid weight loss and metabolic changes to subside

4 BARIATRIC SURGERY IN REPRODUCTIVE WOMEN

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)

The foregut hypothesis theory ndash 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

Effect of Bariatric Surgery on Diabetes Mellitus

Combined Gastric Restriction amp Malabsorption

Operative Risks (vs cholecystectomy)

Perioperative Mortality 1-2 vs 02-08 Early Complications 10 vs 29Late Complications 20 vs 1-2

LimitationsWidening of (unbanded) gastrojejunostomyExpansion of gastric pouch 25 with nearly 100 weight regainAdaptation of limb that receives the food

SUMMARY OF ALL TYPES OF SURGERY

bull LRYGBP ndash worlds best procedure 60-70 WL dumping syndrome malnutrition

bull LAGB- low complications varying range of wt loss frequent post-op visits ( 10)

bull DSBPD- more wt loss high complications good for high BMI gt 50 malabsorption +

bull VBG(vertical band gastroplasty) ndash longest available results good wt loss improved co-morbidities right for some ptsrisks too high to justify rewards

bull SG- needs long term research 1st step procedure low risks higher wt loss lesser complications pouch could Stretch over time long staple line could cause problems in future frequency is accelerating because of technical ease 1st stage procedure before bypass

Post-surgical Complications

Anastomosis leaks or staple line leaks Pulmonary Embolism or DVT Cholelithiasis Stomal ulceration Dumping syndrome Constipation

Anastamosis Leaks

Up to 7-10 days after surgery Most common at gastrojejunostomy enteroenterostomy Roux

limb stump staple line Can lead to peritonitis sepsis possible death Presentation

Tachycardia tachypnea Fever Ab painback pain Pelvic pressure or rebound tenderness

Anastamosis Leaks

Order Gastrograffin upper GI series Subclinical cases

Bowel rest Parenteral nutrition IV antibiotic if H pylori

Clinically suspect leak Laparoscopic evaluation and leak repair

Failure to evaluate is the most common cause of preventable major long-term disability or death in bariatric surgical patients

Pulmonary Embolism

Sudden cause of death up to one month after surgery 20-30 mortality rate High risk may have vena cava filter placement prior to surgery Prophylaxis with compression stockings and LMWH Early ambulation imperitive

Pulmonary Embolism

Presentation Profound hypoxia Hypotension Signs of sepsis

Immediate spiral chest CT Abdominal exploration if too large for machine No pathology start anticoagulation Too largehelliphellipNO SURGERY

Cholelithiasis

Up to 36 of patients within 6 months post-op Bile stasis leads to increased sludge and gallstones Prophylactic cholecystectomy prior to surgery if

evidence of existing sludge or stones Prevent post-operative disease with concurrent bariatric

surgery and cholecystectomy Prophylactic use of urosidol

Expensive and unpalatable

Stomal Ulceration

12-15 within 2-4 mos Post-surgery Etiology

Overabundant acid in pouch leads to excessive acid passing through stoma

Pouch tension and staple line breakdown NSAID use

Presentation Dyspepsia vomiting Epigastric or retrosternal pain

Stomal Ulceration

Treatment PPI carafate Antibiotics if H Pylori Avoid NSAIDS alcohol smoking

If no response to treatment Endoscopy Back to surgery for pouch revision or staple line repair

Dumping Syndrome

More than 15 patients Hypotention Tachycardia Lightheadedness syncope Flushing Abdominal cramping and diarrhea Nausea and vomiting

Dumping Syndrome

Occurs with high dose simple sugar ingestion Sugar in small intestine causes osmotic overload and fluid

shift from blood to intestine Increased intestinal volume leads to watery diarrhea Decreased blood volume leads to systemic changes Patient education

Eat slowly Avoid drinking before during and not until 30 minutes after meals

Constipation

Most common complaint Causes

Dehydration and decreased fluid intake post-operatively Increased metabolic water needs Calcium and iron supplement use following surgery

Treat with increased fluids and stool softeners

Nutritional Consequences

Iron deficiency anemia B12 deficiency Folate deficiency Calcium and Vitamin D deficiency

Not seen with purely restrictive surgeries

Iron deficiency and anemia

Common following RYGB As high as 49 of patients Multifactorial cause

Low gastric acid levels prohibit iron cleavage from food Absorption inhibited because no nutrient exposure to duodenum or

proximal jejunum Decrease in iron-rich food consumption due to intolerance

Treat with oral supplementation of ferrous sulfate or ferrous gluconate

Vitamin B12 deficiency

Up to 70 of patients Lack of hydrochloric acid and pepsin in stomach

Prevents B12 cleavage from food Affects secretion of intrinsic factor thus B12 absorption

Intolerance to meat and milk Oral supplementation usually adequate otherwise IM injections used

Folate Deficiency

40 of gastric bypass patients Complete absorption requires B12 Absorption dependent on HCl and upper 13 stomach Deficiency generally caused by decreased consumption Oral supplementation

Vitamin D and Calcium Deficiency

Vitamin D deficiency is common among obese people Calcium absorption decreased because duodenum is

bypassed Intolerance to dairy foods high in calcium Vitamin D is required for Ca++ absorption Prolonged deficiencies lead to

Bone resorption osteomalacia osteoporosis Treat with calcium citrate supplementation and 2 weekly

doses of Vitamin D

Nutritional Implications of Various Bariatric Surgeries(34)

bull RYGB Malabsorption of Vit B12 Vit B1 (thiamin) Vit D Vit K Folate Iron Calcium

bull LAGB Folic Acid deficiency

bull BPD and BPDDS Vit A D E and K deficiency Protein-Calorie Malnutrition Malabsorption of

Calcium Zinc Selenium Sodium Potassium Chloride Phosphorus Magnesium

Recommended Daily Supplements(4)

Multivitamin with iron (prenatal vitamin will have adeq amount of folic acid)

Calcium (citrate) with vitamin D (1200-1500 mg calcium with 800-1000 IU vitamin D)

Oral vitamin B12 (500-1000 mcg) Iron (65 mgday in elemental form)

Vitamin C (to increase absorption of Iron) Thiamin (10 mgday)

Diet Recommendations(3)

Reduce food volume Chew food very well Slow pace of eating No liquids with meals Encourage fruits and vegetables as diet progresses Include high protein foods (at least 60gday) may need protein

supplements

Diet Progression Gastric Bypass

Stage 1 Clear liquids and protein supplement (1 week)

Stage 2No concentrated sweets low fat puree diet ( 3 weeks)

Stage 3 Regular texture weight reduction diet

Diet Progression Lap - Band

Stage 1 Clear liquids and protein supplement ( 2 weeks)

Stage 2 No concentrated sweets low fat puree diet (2weeks)

Stage 3 Regular texture weight reduction diet

Stage 1

Only clear liquids allowed Avoid sweetened beverages Sip very slowly No straws Avoid caffeinated carbonated and alcoholic beverages STOP drinking if you feel fullness pain or discomfort

Protein supplements

Begin the day after you go home from Hospital

Minimum protein target 70gmsday

May use powder or pre-mixed liquid forms (Whey protein is preferred)

Protein pills may not be used

Vitamin and Mineral Supplements

Gastric bypass patients In addition to eating much less food gastric bypass patients will also

absorb vitamins and minerals differently after surgery They will require daily multivitamin calcium and iron

supplementation for the rest of your life

Vitamin and Mineral Supplements

Lap-Bandreg patients

Require a multivitamin with minerals daily

It may be necessary to take additional vitamins and minerals eg calcium iron folateB1 B12These will be prescribed as needed

Stage 2 dietPUREE

Puree diet

Regular scheduled meals Avoid meal skipping Plan meals in advance Eat Slowly Eat protein foods first Moisten meats Use liquid protein as supplement not as meal replacement

Measure 2 oz portions at each meal eating when full Separate liquids and solids No bread rice or pasta Avoid added sugars and high fat

foods VARIETY

bull Most women regained normal menstrual function and most had documented

spontaneous ovulation

bull Significant improvement in hirsutism androgen profiles and about a 50 reduction in

HOMA-IR

bull Follow up for more than 2 years showed that all women resumed normal menstrual

cycles HbA1C decreased from 82 to 51 in lt 3 months

bull 78 saw improvement in metabolic syndrome amp 48 showed improvement in PCOS

2 ROLE OF BARIATRIC SURGERY IN PCOS PATIENTS

bull Decrease menstrual irregularities bull PCOS women have less hyper androgenism

bull Sex hormone binding globulin increases bull LH and FSH levels have been reported to increase

bull Ovulatory function measured by luteal LH and Progesterone secretion improved bull Leptin levels decrease reflecting improved reproductive metabolic status

bull Subclinical hypothyroidism significantly reduced

THE SAFE TIMING OF PREGNANCYoptimal or minimal time gt12 months after bariatric surgery before becoming pregnant in order to allow the rapid weight loss and metabolic changes to subside

4 BARIATRIC SURGERY IN REPRODUCTIVE WOMEN

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)

The foregut hypothesis theory ndash 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

Effect of Bariatric Surgery on Diabetes Mellitus

Combined Gastric Restriction amp Malabsorption

Operative Risks (vs cholecystectomy)

Perioperative Mortality 1-2 vs 02-08 Early Complications 10 vs 29Late Complications 20 vs 1-2

LimitationsWidening of (unbanded) gastrojejunostomyExpansion of gastric pouch 25 with nearly 100 weight regainAdaptation of limb that receives the food

SUMMARY OF ALL TYPES OF SURGERY

bull LRYGBP ndash worlds best procedure 60-70 WL dumping syndrome malnutrition

bull LAGB- low complications varying range of wt loss frequent post-op visits ( 10)

bull DSBPD- more wt loss high complications good for high BMI gt 50 malabsorption +

bull VBG(vertical band gastroplasty) ndash longest available results good wt loss improved co-morbidities right for some ptsrisks too high to justify rewards

bull SG- needs long term research 1st step procedure low risks higher wt loss lesser complications pouch could Stretch over time long staple line could cause problems in future frequency is accelerating because of technical ease 1st stage procedure before bypass

Post-surgical Complications

Anastomosis leaks or staple line leaks Pulmonary Embolism or DVT Cholelithiasis Stomal ulceration Dumping syndrome Constipation

Anastamosis Leaks

Up to 7-10 days after surgery Most common at gastrojejunostomy enteroenterostomy Roux

limb stump staple line Can lead to peritonitis sepsis possible death Presentation

Tachycardia tachypnea Fever Ab painback pain Pelvic pressure or rebound tenderness

Anastamosis Leaks

Order Gastrograffin upper GI series Subclinical cases

Bowel rest Parenteral nutrition IV antibiotic if H pylori

Clinically suspect leak Laparoscopic evaluation and leak repair

Failure to evaluate is the most common cause of preventable major long-term disability or death in bariatric surgical patients

Pulmonary Embolism

Sudden cause of death up to one month after surgery 20-30 mortality rate High risk may have vena cava filter placement prior to surgery Prophylaxis with compression stockings and LMWH Early ambulation imperitive

Pulmonary Embolism

Presentation Profound hypoxia Hypotension Signs of sepsis

Immediate spiral chest CT Abdominal exploration if too large for machine No pathology start anticoagulation Too largehelliphellipNO SURGERY

Cholelithiasis

Up to 36 of patients within 6 months post-op Bile stasis leads to increased sludge and gallstones Prophylactic cholecystectomy prior to surgery if

evidence of existing sludge or stones Prevent post-operative disease with concurrent bariatric

surgery and cholecystectomy Prophylactic use of urosidol

Expensive and unpalatable

Stomal Ulceration

12-15 within 2-4 mos Post-surgery Etiology

Overabundant acid in pouch leads to excessive acid passing through stoma

Pouch tension and staple line breakdown NSAID use

Presentation Dyspepsia vomiting Epigastric or retrosternal pain

Stomal Ulceration

Treatment PPI carafate Antibiotics if H Pylori Avoid NSAIDS alcohol smoking

If no response to treatment Endoscopy Back to surgery for pouch revision or staple line repair

Dumping Syndrome

More than 15 patients Hypotention Tachycardia Lightheadedness syncope Flushing Abdominal cramping and diarrhea Nausea and vomiting

Dumping Syndrome

Occurs with high dose simple sugar ingestion Sugar in small intestine causes osmotic overload and fluid

shift from blood to intestine Increased intestinal volume leads to watery diarrhea Decreased blood volume leads to systemic changes Patient education

Eat slowly Avoid drinking before during and not until 30 minutes after meals

Constipation

Most common complaint Causes

Dehydration and decreased fluid intake post-operatively Increased metabolic water needs Calcium and iron supplement use following surgery

Treat with increased fluids and stool softeners

Nutritional Consequences

Iron deficiency anemia B12 deficiency Folate deficiency Calcium and Vitamin D deficiency

Not seen with purely restrictive surgeries

Iron deficiency and anemia

Common following RYGB As high as 49 of patients Multifactorial cause

Low gastric acid levels prohibit iron cleavage from food Absorption inhibited because no nutrient exposure to duodenum or

proximal jejunum Decrease in iron-rich food consumption due to intolerance

Treat with oral supplementation of ferrous sulfate or ferrous gluconate

Vitamin B12 deficiency

Up to 70 of patients Lack of hydrochloric acid and pepsin in stomach

Prevents B12 cleavage from food Affects secretion of intrinsic factor thus B12 absorption

Intolerance to meat and milk Oral supplementation usually adequate otherwise IM injections used

Folate Deficiency

40 of gastric bypass patients Complete absorption requires B12 Absorption dependent on HCl and upper 13 stomach Deficiency generally caused by decreased consumption Oral supplementation

Vitamin D and Calcium Deficiency

Vitamin D deficiency is common among obese people Calcium absorption decreased because duodenum is

bypassed Intolerance to dairy foods high in calcium Vitamin D is required for Ca++ absorption Prolonged deficiencies lead to

Bone resorption osteomalacia osteoporosis Treat with calcium citrate supplementation and 2 weekly

doses of Vitamin D

Nutritional Implications of Various Bariatric Surgeries(34)

bull RYGB Malabsorption of Vit B12 Vit B1 (thiamin) Vit D Vit K Folate Iron Calcium

bull LAGB Folic Acid deficiency

bull BPD and BPDDS Vit A D E and K deficiency Protein-Calorie Malnutrition Malabsorption of

Calcium Zinc Selenium Sodium Potassium Chloride Phosphorus Magnesium

Recommended Daily Supplements(4)

Multivitamin with iron (prenatal vitamin will have adeq amount of folic acid)

Calcium (citrate) with vitamin D (1200-1500 mg calcium with 800-1000 IU vitamin D)

Oral vitamin B12 (500-1000 mcg) Iron (65 mgday in elemental form)

Vitamin C (to increase absorption of Iron) Thiamin (10 mgday)

Diet Recommendations(3)

Reduce food volume Chew food very well Slow pace of eating No liquids with meals Encourage fruits and vegetables as diet progresses Include high protein foods (at least 60gday) may need protein

supplements

Diet Progression Gastric Bypass

Stage 1 Clear liquids and protein supplement (1 week)

Stage 2No concentrated sweets low fat puree diet ( 3 weeks)

Stage 3 Regular texture weight reduction diet

Diet Progression Lap - Band

Stage 1 Clear liquids and protein supplement ( 2 weeks)

Stage 2 No concentrated sweets low fat puree diet (2weeks)

Stage 3 Regular texture weight reduction diet

Stage 1

Only clear liquids allowed Avoid sweetened beverages Sip very slowly No straws Avoid caffeinated carbonated and alcoholic beverages STOP drinking if you feel fullness pain or discomfort

Protein supplements

Begin the day after you go home from Hospital

Minimum protein target 70gmsday

May use powder or pre-mixed liquid forms (Whey protein is preferred)

Protein pills may not be used

Vitamin and Mineral Supplements

Gastric bypass patients In addition to eating much less food gastric bypass patients will also

absorb vitamins and minerals differently after surgery They will require daily multivitamin calcium and iron

supplementation for the rest of your life

Vitamin and Mineral Supplements

Lap-Bandreg patients

Require a multivitamin with minerals daily

It may be necessary to take additional vitamins and minerals eg calcium iron folateB1 B12These will be prescribed as needed

Stage 2 dietPUREE

Puree diet

Regular scheduled meals Avoid meal skipping Plan meals in advance Eat Slowly Eat protein foods first Moisten meats Use liquid protein as supplement not as meal replacement

Measure 2 oz portions at each meal eating when full Separate liquids and solids No bread rice or pasta Avoid added sugars and high fat

foods VARIETY

bull Decrease menstrual irregularities bull PCOS women have less hyper androgenism

bull Sex hormone binding globulin increases bull LH and FSH levels have been reported to increase

bull Ovulatory function measured by luteal LH and Progesterone secretion improved bull Leptin levels decrease reflecting improved reproductive metabolic status

bull Subclinical hypothyroidism significantly reduced

THE SAFE TIMING OF PREGNANCYoptimal or minimal time gt12 months after bariatric surgery before becoming pregnant in order to allow the rapid weight loss and metabolic changes to subside

4 BARIATRIC SURGERY IN REPRODUCTIVE WOMEN

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)

The foregut hypothesis theory ndash 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

Effect of Bariatric Surgery on Diabetes Mellitus

Combined Gastric Restriction amp Malabsorption

Operative Risks (vs cholecystectomy)

Perioperative Mortality 1-2 vs 02-08 Early Complications 10 vs 29Late Complications 20 vs 1-2

LimitationsWidening of (unbanded) gastrojejunostomyExpansion of gastric pouch 25 with nearly 100 weight regainAdaptation of limb that receives the food

SUMMARY OF ALL TYPES OF SURGERY

bull LRYGBP ndash worlds best procedure 60-70 WL dumping syndrome malnutrition

bull LAGB- low complications varying range of wt loss frequent post-op visits ( 10)

bull DSBPD- more wt loss high complications good for high BMI gt 50 malabsorption +

bull VBG(vertical band gastroplasty) ndash longest available results good wt loss improved co-morbidities right for some ptsrisks too high to justify rewards

bull SG- needs long term research 1st step procedure low risks higher wt loss lesser complications pouch could Stretch over time long staple line could cause problems in future frequency is accelerating because of technical ease 1st stage procedure before bypass

Post-surgical Complications

Anastomosis leaks or staple line leaks Pulmonary Embolism or DVT Cholelithiasis Stomal ulceration Dumping syndrome Constipation

Anastamosis Leaks

Up to 7-10 days after surgery Most common at gastrojejunostomy enteroenterostomy Roux

limb stump staple line Can lead to peritonitis sepsis possible death Presentation

Tachycardia tachypnea Fever Ab painback pain Pelvic pressure or rebound tenderness

Anastamosis Leaks

Order Gastrograffin upper GI series Subclinical cases

Bowel rest Parenteral nutrition IV antibiotic if H pylori

Clinically suspect leak Laparoscopic evaluation and leak repair

Failure to evaluate is the most common cause of preventable major long-term disability or death in bariatric surgical patients

Pulmonary Embolism

Sudden cause of death up to one month after surgery 20-30 mortality rate High risk may have vena cava filter placement prior to surgery Prophylaxis with compression stockings and LMWH Early ambulation imperitive

Pulmonary Embolism

Presentation Profound hypoxia Hypotension Signs of sepsis

Immediate spiral chest CT Abdominal exploration if too large for machine No pathology start anticoagulation Too largehelliphellipNO SURGERY

Cholelithiasis

Up to 36 of patients within 6 months post-op Bile stasis leads to increased sludge and gallstones Prophylactic cholecystectomy prior to surgery if

evidence of existing sludge or stones Prevent post-operative disease with concurrent bariatric

surgery and cholecystectomy Prophylactic use of urosidol

Expensive and unpalatable

Stomal Ulceration

12-15 within 2-4 mos Post-surgery Etiology

Overabundant acid in pouch leads to excessive acid passing through stoma

Pouch tension and staple line breakdown NSAID use

Presentation Dyspepsia vomiting Epigastric or retrosternal pain

Stomal Ulceration

Treatment PPI carafate Antibiotics if H Pylori Avoid NSAIDS alcohol smoking

If no response to treatment Endoscopy Back to surgery for pouch revision or staple line repair

Dumping Syndrome

More than 15 patients Hypotention Tachycardia Lightheadedness syncope Flushing Abdominal cramping and diarrhea Nausea and vomiting

Dumping Syndrome

Occurs with high dose simple sugar ingestion Sugar in small intestine causes osmotic overload and fluid

shift from blood to intestine Increased intestinal volume leads to watery diarrhea Decreased blood volume leads to systemic changes Patient education

Eat slowly Avoid drinking before during and not until 30 minutes after meals

Constipation

Most common complaint Causes

Dehydration and decreased fluid intake post-operatively Increased metabolic water needs Calcium and iron supplement use following surgery

Treat with increased fluids and stool softeners

Nutritional Consequences

Iron deficiency anemia B12 deficiency Folate deficiency Calcium and Vitamin D deficiency

Not seen with purely restrictive surgeries

Iron deficiency and anemia

Common following RYGB As high as 49 of patients Multifactorial cause

Low gastric acid levels prohibit iron cleavage from food Absorption inhibited because no nutrient exposure to duodenum or

proximal jejunum Decrease in iron-rich food consumption due to intolerance

Treat with oral supplementation of ferrous sulfate or ferrous gluconate

Vitamin B12 deficiency

Up to 70 of patients Lack of hydrochloric acid and pepsin in stomach

Prevents B12 cleavage from food Affects secretion of intrinsic factor thus B12 absorption

Intolerance to meat and milk Oral supplementation usually adequate otherwise IM injections used

Folate Deficiency

40 of gastric bypass patients Complete absorption requires B12 Absorption dependent on HCl and upper 13 stomach Deficiency generally caused by decreased consumption Oral supplementation

Vitamin D and Calcium Deficiency

Vitamin D deficiency is common among obese people Calcium absorption decreased because duodenum is

bypassed Intolerance to dairy foods high in calcium Vitamin D is required for Ca++ absorption Prolonged deficiencies lead to

Bone resorption osteomalacia osteoporosis Treat with calcium citrate supplementation and 2 weekly

doses of Vitamin D

Nutritional Implications of Various Bariatric Surgeries(34)

bull RYGB Malabsorption of Vit B12 Vit B1 (thiamin) Vit D Vit K Folate Iron Calcium

bull LAGB Folic Acid deficiency

bull BPD and BPDDS Vit A D E and K deficiency Protein-Calorie Malnutrition Malabsorption of

Calcium Zinc Selenium Sodium Potassium Chloride Phosphorus Magnesium

Recommended Daily Supplements(4)

Multivitamin with iron (prenatal vitamin will have adeq amount of folic acid)

Calcium (citrate) with vitamin D (1200-1500 mg calcium with 800-1000 IU vitamin D)

Oral vitamin B12 (500-1000 mcg) Iron (65 mgday in elemental form)

Vitamin C (to increase absorption of Iron) Thiamin (10 mgday)

Diet Recommendations(3)

Reduce food volume Chew food very well Slow pace of eating No liquids with meals Encourage fruits and vegetables as diet progresses Include high protein foods (at least 60gday) may need protein

supplements

Diet Progression Gastric Bypass

Stage 1 Clear liquids and protein supplement (1 week)

Stage 2No concentrated sweets low fat puree diet ( 3 weeks)

Stage 3 Regular texture weight reduction diet

Diet Progression Lap - Band

Stage 1 Clear liquids and protein supplement ( 2 weeks)

Stage 2 No concentrated sweets low fat puree diet (2weeks)

Stage 3 Regular texture weight reduction diet

Stage 1

Only clear liquids allowed Avoid sweetened beverages Sip very slowly No straws Avoid caffeinated carbonated and alcoholic beverages STOP drinking if you feel fullness pain or discomfort

Protein supplements

Begin the day after you go home from Hospital

Minimum protein target 70gmsday

May use powder or pre-mixed liquid forms (Whey protein is preferred)

Protein pills may not be used

Vitamin and Mineral Supplements

Gastric bypass patients In addition to eating much less food gastric bypass patients will also

absorb vitamins and minerals differently after surgery They will require daily multivitamin calcium and iron

supplementation for the rest of your life

Vitamin and Mineral Supplements

Lap-Bandreg patients

Require a multivitamin with minerals daily

It may be necessary to take additional vitamins and minerals eg calcium iron folateB1 B12These will be prescribed as needed

Stage 2 dietPUREE

Puree diet

Regular scheduled meals Avoid meal skipping Plan meals in advance Eat Slowly Eat protein foods first Moisten meats Use liquid protein as supplement not as meal replacement

Measure 2 oz portions at each meal eating when full Separate liquids and solids No bread rice or pasta Avoid added sugars and high fat

foods VARIETY

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)

The foregut hypothesis theory ndash 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

Effect of Bariatric Surgery on Diabetes Mellitus

Combined Gastric Restriction amp Malabsorption

Operative Risks (vs cholecystectomy)

Perioperative Mortality 1-2 vs 02-08 Early Complications 10 vs 29Late Complications 20 vs 1-2

LimitationsWidening of (unbanded) gastrojejunostomyExpansion of gastric pouch 25 with nearly 100 weight regainAdaptation of limb that receives the food

SUMMARY OF ALL TYPES OF SURGERY

bull LRYGBP ndash worlds best procedure 60-70 WL dumping syndrome malnutrition

bull LAGB- low complications varying range of wt loss frequent post-op visits ( 10)

bull DSBPD- more wt loss high complications good for high BMI gt 50 malabsorption +

bull VBG(vertical band gastroplasty) ndash longest available results good wt loss improved co-morbidities right for some ptsrisks too high to justify rewards

bull SG- needs long term research 1st step procedure low risks higher wt loss lesser complications pouch could Stretch over time long staple line could cause problems in future frequency is accelerating because of technical ease 1st stage procedure before bypass

Post-surgical Complications

Anastomosis leaks or staple line leaks Pulmonary Embolism or DVT Cholelithiasis Stomal ulceration Dumping syndrome Constipation

Anastamosis Leaks

Up to 7-10 days after surgery Most common at gastrojejunostomy enteroenterostomy Roux

limb stump staple line Can lead to peritonitis sepsis possible death Presentation

Tachycardia tachypnea Fever Ab painback pain Pelvic pressure or rebound tenderness

Anastamosis Leaks

Order Gastrograffin upper GI series Subclinical cases

Bowel rest Parenteral nutrition IV antibiotic if H pylori

Clinically suspect leak Laparoscopic evaluation and leak repair

Failure to evaluate is the most common cause of preventable major long-term disability or death in bariatric surgical patients

Pulmonary Embolism

Sudden cause of death up to one month after surgery 20-30 mortality rate High risk may have vena cava filter placement prior to surgery Prophylaxis with compression stockings and LMWH Early ambulation imperitive

Pulmonary Embolism

Presentation Profound hypoxia Hypotension Signs of sepsis

Immediate spiral chest CT Abdominal exploration if too large for machine No pathology start anticoagulation Too largehelliphellipNO SURGERY

Cholelithiasis

Up to 36 of patients within 6 months post-op Bile stasis leads to increased sludge and gallstones Prophylactic cholecystectomy prior to surgery if

evidence of existing sludge or stones Prevent post-operative disease with concurrent bariatric

surgery and cholecystectomy Prophylactic use of urosidol

Expensive and unpalatable

Stomal Ulceration

12-15 within 2-4 mos Post-surgery Etiology

Overabundant acid in pouch leads to excessive acid passing through stoma

Pouch tension and staple line breakdown NSAID use

Presentation Dyspepsia vomiting Epigastric or retrosternal pain

Stomal Ulceration

Treatment PPI carafate Antibiotics if H Pylori Avoid NSAIDS alcohol smoking

If no response to treatment Endoscopy Back to surgery for pouch revision or staple line repair

Dumping Syndrome

More than 15 patients Hypotention Tachycardia Lightheadedness syncope Flushing Abdominal cramping and diarrhea Nausea and vomiting

Dumping Syndrome

Occurs with high dose simple sugar ingestion Sugar in small intestine causes osmotic overload and fluid

shift from blood to intestine Increased intestinal volume leads to watery diarrhea Decreased blood volume leads to systemic changes Patient education

Eat slowly Avoid drinking before during and not until 30 minutes after meals

Constipation

Most common complaint Causes

Dehydration and decreased fluid intake post-operatively Increased metabolic water needs Calcium and iron supplement use following surgery

Treat with increased fluids and stool softeners

Nutritional Consequences

Iron deficiency anemia B12 deficiency Folate deficiency Calcium and Vitamin D deficiency

Not seen with purely restrictive surgeries

Iron deficiency and anemia

Common following RYGB As high as 49 of patients Multifactorial cause

Low gastric acid levels prohibit iron cleavage from food Absorption inhibited because no nutrient exposure to duodenum or

proximal jejunum Decrease in iron-rich food consumption due to intolerance

Treat with oral supplementation of ferrous sulfate or ferrous gluconate

Vitamin B12 deficiency

Up to 70 of patients Lack of hydrochloric acid and pepsin in stomach

Prevents B12 cleavage from food Affects secretion of intrinsic factor thus B12 absorption

Intolerance to meat and milk Oral supplementation usually adequate otherwise IM injections used

Folate Deficiency

40 of gastric bypass patients Complete absorption requires B12 Absorption dependent on HCl and upper 13 stomach Deficiency generally caused by decreased consumption Oral supplementation

Vitamin D and Calcium Deficiency

Vitamin D deficiency is common among obese people Calcium absorption decreased because duodenum is

bypassed Intolerance to dairy foods high in calcium Vitamin D is required for Ca++ absorption Prolonged deficiencies lead to

Bone resorption osteomalacia osteoporosis Treat with calcium citrate supplementation and 2 weekly

doses of Vitamin D

Nutritional Implications of Various Bariatric Surgeries(34)

bull RYGB Malabsorption of Vit B12 Vit B1 (thiamin) Vit D Vit K Folate Iron Calcium

bull LAGB Folic Acid deficiency

bull BPD and BPDDS Vit A D E and K deficiency Protein-Calorie Malnutrition Malabsorption of

Calcium Zinc Selenium Sodium Potassium Chloride Phosphorus Magnesium

Recommended Daily Supplements(4)

Multivitamin with iron (prenatal vitamin will have adeq amount of folic acid)

Calcium (citrate) with vitamin D (1200-1500 mg calcium with 800-1000 IU vitamin D)

Oral vitamin B12 (500-1000 mcg) Iron (65 mgday in elemental form)

Vitamin C (to increase absorption of Iron) Thiamin (10 mgday)

Diet Recommendations(3)

Reduce food volume Chew food very well Slow pace of eating No liquids with meals Encourage fruits and vegetables as diet progresses Include high protein foods (at least 60gday) may need protein

supplements

Diet Progression Gastric Bypass

Stage 1 Clear liquids and protein supplement (1 week)

Stage 2No concentrated sweets low fat puree diet ( 3 weeks)

Stage 3 Regular texture weight reduction diet

Diet Progression Lap - Band

Stage 1 Clear liquids and protein supplement ( 2 weeks)

Stage 2 No concentrated sweets low fat puree diet (2weeks)

Stage 3 Regular texture weight reduction diet

Stage 1

Only clear liquids allowed Avoid sweetened beverages Sip very slowly No straws Avoid caffeinated carbonated and alcoholic beverages STOP drinking if you feel fullness pain or discomfort

Protein supplements

Begin the day after you go home from Hospital

Minimum protein target 70gmsday

May use powder or pre-mixed liquid forms (Whey protein is preferred)

Protein pills may not be used

Vitamin and Mineral Supplements

Gastric bypass patients In addition to eating much less food gastric bypass patients will also

absorb vitamins and minerals differently after surgery They will require daily multivitamin calcium and iron

supplementation for the rest of your life

Vitamin and Mineral Supplements

Lap-Bandreg patients

Require a multivitamin with minerals daily

It may be necessary to take additional vitamins and minerals eg calcium iron folateB1 B12These will be prescribed as needed

Stage 2 dietPUREE

Puree diet

Regular scheduled meals Avoid meal skipping Plan meals in advance Eat Slowly Eat protein foods first Moisten meats Use liquid protein as supplement not as meal replacement

Measure 2 oz portions at each meal eating when full Separate liquids and solids No bread rice or pasta Avoid added sugars and high fat

foods VARIETY

Combined Gastric Restriction amp Malabsorption

Operative Risks (vs cholecystectomy)

Perioperative Mortality 1-2 vs 02-08 Early Complications 10 vs 29Late Complications 20 vs 1-2

LimitationsWidening of (unbanded) gastrojejunostomyExpansion of gastric pouch 25 with nearly 100 weight regainAdaptation of limb that receives the food

SUMMARY OF ALL TYPES OF SURGERY

bull LRYGBP ndash worlds best procedure 60-70 WL dumping syndrome malnutrition

bull LAGB- low complications varying range of wt loss frequent post-op visits ( 10)

bull DSBPD- more wt loss high complications good for high BMI gt 50 malabsorption +

bull VBG(vertical band gastroplasty) ndash longest available results good wt loss improved co-morbidities right for some ptsrisks too high to justify rewards

bull SG- needs long term research 1st step procedure low risks higher wt loss lesser complications pouch could Stretch over time long staple line could cause problems in future frequency is accelerating because of technical ease 1st stage procedure before bypass

Post-surgical Complications

Anastomosis leaks or staple line leaks Pulmonary Embolism or DVT Cholelithiasis Stomal ulceration Dumping syndrome Constipation

Anastamosis Leaks

Up to 7-10 days after surgery Most common at gastrojejunostomy enteroenterostomy Roux

limb stump staple line Can lead to peritonitis sepsis possible death Presentation

Tachycardia tachypnea Fever Ab painback pain Pelvic pressure or rebound tenderness

Anastamosis Leaks

Order Gastrograffin upper GI series Subclinical cases

Bowel rest Parenteral nutrition IV antibiotic if H pylori

Clinically suspect leak Laparoscopic evaluation and leak repair

Failure to evaluate is the most common cause of preventable major long-term disability or death in bariatric surgical patients

Pulmonary Embolism

Sudden cause of death up to one month after surgery 20-30 mortality rate High risk may have vena cava filter placement prior to surgery Prophylaxis with compression stockings and LMWH Early ambulation imperitive

Pulmonary Embolism

Presentation Profound hypoxia Hypotension Signs of sepsis

Immediate spiral chest CT Abdominal exploration if too large for machine No pathology start anticoagulation Too largehelliphellipNO SURGERY

Cholelithiasis

Up to 36 of patients within 6 months post-op Bile stasis leads to increased sludge and gallstones Prophylactic cholecystectomy prior to surgery if

evidence of existing sludge or stones Prevent post-operative disease with concurrent bariatric

surgery and cholecystectomy Prophylactic use of urosidol

Expensive and unpalatable

Stomal Ulceration

12-15 within 2-4 mos Post-surgery Etiology

Overabundant acid in pouch leads to excessive acid passing through stoma

Pouch tension and staple line breakdown NSAID use

Presentation Dyspepsia vomiting Epigastric or retrosternal pain

Stomal Ulceration

Treatment PPI carafate Antibiotics if H Pylori Avoid NSAIDS alcohol smoking

If no response to treatment Endoscopy Back to surgery for pouch revision or staple line repair

Dumping Syndrome

More than 15 patients Hypotention Tachycardia Lightheadedness syncope Flushing Abdominal cramping and diarrhea Nausea and vomiting

Dumping Syndrome

Occurs with high dose simple sugar ingestion Sugar in small intestine causes osmotic overload and fluid

shift from blood to intestine Increased intestinal volume leads to watery diarrhea Decreased blood volume leads to systemic changes Patient education

Eat slowly Avoid drinking before during and not until 30 minutes after meals

Constipation

Most common complaint Causes

Dehydration and decreased fluid intake post-operatively Increased metabolic water needs Calcium and iron supplement use following surgery

Treat with increased fluids and stool softeners

Nutritional Consequences

Iron deficiency anemia B12 deficiency Folate deficiency Calcium and Vitamin D deficiency

Not seen with purely restrictive surgeries

Iron deficiency and anemia

Common following RYGB As high as 49 of patients Multifactorial cause

Low gastric acid levels prohibit iron cleavage from food Absorption inhibited because no nutrient exposure to duodenum or

proximal jejunum Decrease in iron-rich food consumption due to intolerance

Treat with oral supplementation of ferrous sulfate or ferrous gluconate

Vitamin B12 deficiency

Up to 70 of patients Lack of hydrochloric acid and pepsin in stomach

Prevents B12 cleavage from food Affects secretion of intrinsic factor thus B12 absorption

Intolerance to meat and milk Oral supplementation usually adequate otherwise IM injections used

Folate Deficiency

40 of gastric bypass patients Complete absorption requires B12 Absorption dependent on HCl and upper 13 stomach Deficiency generally caused by decreased consumption Oral supplementation

Vitamin D and Calcium Deficiency

Vitamin D deficiency is common among obese people Calcium absorption decreased because duodenum is

bypassed Intolerance to dairy foods high in calcium Vitamin D is required for Ca++ absorption Prolonged deficiencies lead to

Bone resorption osteomalacia osteoporosis Treat with calcium citrate supplementation and 2 weekly

doses of Vitamin D

Nutritional Implications of Various Bariatric Surgeries(34)

bull RYGB Malabsorption of Vit B12 Vit B1 (thiamin) Vit D Vit K Folate Iron Calcium

bull LAGB Folic Acid deficiency

bull BPD and BPDDS Vit A D E and K deficiency Protein-Calorie Malnutrition Malabsorption of

Calcium Zinc Selenium Sodium Potassium Chloride Phosphorus Magnesium

Recommended Daily Supplements(4)

Multivitamin with iron (prenatal vitamin will have adeq amount of folic acid)

Calcium (citrate) with vitamin D (1200-1500 mg calcium with 800-1000 IU vitamin D)

Oral vitamin B12 (500-1000 mcg) Iron (65 mgday in elemental form)

Vitamin C (to increase absorption of Iron) Thiamin (10 mgday)

Diet Recommendations(3)

Reduce food volume Chew food very well Slow pace of eating No liquids with meals Encourage fruits and vegetables as diet progresses Include high protein foods (at least 60gday) may need protein

supplements

Diet Progression Gastric Bypass

Stage 1 Clear liquids and protein supplement (1 week)

Stage 2No concentrated sweets low fat puree diet ( 3 weeks)

Stage 3 Regular texture weight reduction diet

Diet Progression Lap - Band

Stage 1 Clear liquids and protein supplement ( 2 weeks)

Stage 2 No concentrated sweets low fat puree diet (2weeks)

Stage 3 Regular texture weight reduction diet

Stage 1

Only clear liquids allowed Avoid sweetened beverages Sip very slowly No straws Avoid caffeinated carbonated and alcoholic beverages STOP drinking if you feel fullness pain or discomfort

Protein supplements

Begin the day after you go home from Hospital

Minimum protein target 70gmsday

May use powder or pre-mixed liquid forms (Whey protein is preferred)

Protein pills may not be used

Vitamin and Mineral Supplements

Gastric bypass patients In addition to eating much less food gastric bypass patients will also

absorb vitamins and minerals differently after surgery They will require daily multivitamin calcium and iron

supplementation for the rest of your life

Vitamin and Mineral Supplements

Lap-Bandreg patients

Require a multivitamin with minerals daily

It may be necessary to take additional vitamins and minerals eg calcium iron folateB1 B12These will be prescribed as needed

Stage 2 dietPUREE

Puree diet

Regular scheduled meals Avoid meal skipping Plan meals in advance Eat Slowly Eat protein foods first Moisten meats Use liquid protein as supplement not as meal replacement

Measure 2 oz portions at each meal eating when full Separate liquids and solids No bread rice or pasta Avoid added sugars and high fat

foods VARIETY

SUMMARY OF ALL TYPES OF SURGERY

bull LRYGBP ndash worlds best procedure 60-70 WL dumping syndrome malnutrition

bull LAGB- low complications varying range of wt loss frequent post-op visits ( 10)

bull DSBPD- more wt loss high complications good for high BMI gt 50 malabsorption +

bull VBG(vertical band gastroplasty) ndash longest available results good wt loss improved co-morbidities right for some ptsrisks too high to justify rewards

bull SG- needs long term research 1st step procedure low risks higher wt loss lesser complications pouch could Stretch over time long staple line could cause problems in future frequency is accelerating because of technical ease 1st stage procedure before bypass

Post-surgical Complications

Anastomosis leaks or staple line leaks Pulmonary Embolism or DVT Cholelithiasis Stomal ulceration Dumping syndrome Constipation

Anastamosis Leaks

Up to 7-10 days after surgery Most common at gastrojejunostomy enteroenterostomy Roux

limb stump staple line Can lead to peritonitis sepsis possible death Presentation

Tachycardia tachypnea Fever Ab painback pain Pelvic pressure or rebound tenderness

Anastamosis Leaks

Order Gastrograffin upper GI series Subclinical cases

Bowel rest Parenteral nutrition IV antibiotic if H pylori

Clinically suspect leak Laparoscopic evaluation and leak repair

Failure to evaluate is the most common cause of preventable major long-term disability or death in bariatric surgical patients

Pulmonary Embolism

Sudden cause of death up to one month after surgery 20-30 mortality rate High risk may have vena cava filter placement prior to surgery Prophylaxis with compression stockings and LMWH Early ambulation imperitive

Pulmonary Embolism

Presentation Profound hypoxia Hypotension Signs of sepsis

Immediate spiral chest CT Abdominal exploration if too large for machine No pathology start anticoagulation Too largehelliphellipNO SURGERY

Cholelithiasis

Up to 36 of patients within 6 months post-op Bile stasis leads to increased sludge and gallstones Prophylactic cholecystectomy prior to surgery if

evidence of existing sludge or stones Prevent post-operative disease with concurrent bariatric

surgery and cholecystectomy Prophylactic use of urosidol

Expensive and unpalatable

Stomal Ulceration

12-15 within 2-4 mos Post-surgery Etiology

Overabundant acid in pouch leads to excessive acid passing through stoma

Pouch tension and staple line breakdown NSAID use

Presentation Dyspepsia vomiting Epigastric or retrosternal pain

Stomal Ulceration

Treatment PPI carafate Antibiotics if H Pylori Avoid NSAIDS alcohol smoking

If no response to treatment Endoscopy Back to surgery for pouch revision or staple line repair

Dumping Syndrome

More than 15 patients Hypotention Tachycardia Lightheadedness syncope Flushing Abdominal cramping and diarrhea Nausea and vomiting

Dumping Syndrome

Occurs with high dose simple sugar ingestion Sugar in small intestine causes osmotic overload and fluid

shift from blood to intestine Increased intestinal volume leads to watery diarrhea Decreased blood volume leads to systemic changes Patient education

Eat slowly Avoid drinking before during and not until 30 minutes after meals

Constipation

Most common complaint Causes

Dehydration and decreased fluid intake post-operatively Increased metabolic water needs Calcium and iron supplement use following surgery

Treat with increased fluids and stool softeners

Nutritional Consequences

Iron deficiency anemia B12 deficiency Folate deficiency Calcium and Vitamin D deficiency

Not seen with purely restrictive surgeries

Iron deficiency and anemia

Common following RYGB As high as 49 of patients Multifactorial cause

Low gastric acid levels prohibit iron cleavage from food Absorption inhibited because no nutrient exposure to duodenum or

proximal jejunum Decrease in iron-rich food consumption due to intolerance

Treat with oral supplementation of ferrous sulfate or ferrous gluconate

Vitamin B12 deficiency

Up to 70 of patients Lack of hydrochloric acid and pepsin in stomach

Prevents B12 cleavage from food Affects secretion of intrinsic factor thus B12 absorption

Intolerance to meat and milk Oral supplementation usually adequate otherwise IM injections used

Folate Deficiency

40 of gastric bypass patients Complete absorption requires B12 Absorption dependent on HCl and upper 13 stomach Deficiency generally caused by decreased consumption Oral supplementation

Vitamin D and Calcium Deficiency

Vitamin D deficiency is common among obese people Calcium absorption decreased because duodenum is

bypassed Intolerance to dairy foods high in calcium Vitamin D is required for Ca++ absorption Prolonged deficiencies lead to

Bone resorption osteomalacia osteoporosis Treat with calcium citrate supplementation and 2 weekly

doses of Vitamin D

Nutritional Implications of Various Bariatric Surgeries(34)

bull RYGB Malabsorption of Vit B12 Vit B1 (thiamin) Vit D Vit K Folate Iron Calcium

bull LAGB Folic Acid deficiency

bull BPD and BPDDS Vit A D E and K deficiency Protein-Calorie Malnutrition Malabsorption of

Calcium Zinc Selenium Sodium Potassium Chloride Phosphorus Magnesium

Recommended Daily Supplements(4)

Multivitamin with iron (prenatal vitamin will have adeq amount of folic acid)

Calcium (citrate) with vitamin D (1200-1500 mg calcium with 800-1000 IU vitamin D)

Oral vitamin B12 (500-1000 mcg) Iron (65 mgday in elemental form)

Vitamin C (to increase absorption of Iron) Thiamin (10 mgday)

Diet Recommendations(3)

Reduce food volume Chew food very well Slow pace of eating No liquids with meals Encourage fruits and vegetables as diet progresses Include high protein foods (at least 60gday) may need protein

supplements

Diet Progression Gastric Bypass

Stage 1 Clear liquids and protein supplement (1 week)

Stage 2No concentrated sweets low fat puree diet ( 3 weeks)

Stage 3 Regular texture weight reduction diet

Diet Progression Lap - Band

Stage 1 Clear liquids and protein supplement ( 2 weeks)

Stage 2 No concentrated sweets low fat puree diet (2weeks)

Stage 3 Regular texture weight reduction diet

Stage 1

Only clear liquids allowed Avoid sweetened beverages Sip very slowly No straws Avoid caffeinated carbonated and alcoholic beverages STOP drinking if you feel fullness pain or discomfort

Protein supplements

Begin the day after you go home from Hospital

Minimum protein target 70gmsday

May use powder or pre-mixed liquid forms (Whey protein is preferred)

Protein pills may not be used

Vitamin and Mineral Supplements

Gastric bypass patients In addition to eating much less food gastric bypass patients will also

absorb vitamins and minerals differently after surgery They will require daily multivitamin calcium and iron

supplementation for the rest of your life

Vitamin and Mineral Supplements

Lap-Bandreg patients

Require a multivitamin with minerals daily

It may be necessary to take additional vitamins and minerals eg calcium iron folateB1 B12These will be prescribed as needed

Stage 2 dietPUREE

Puree diet

Regular scheduled meals Avoid meal skipping Plan meals in advance Eat Slowly Eat protein foods first Moisten meats Use liquid protein as supplement not as meal replacement

Measure 2 oz portions at each meal eating when full Separate liquids and solids No bread rice or pasta Avoid added sugars and high fat

foods VARIETY

Post-surgical Complications

Anastomosis leaks or staple line leaks Pulmonary Embolism or DVT Cholelithiasis Stomal ulceration Dumping syndrome Constipation

Anastamosis Leaks

Up to 7-10 days after surgery Most common at gastrojejunostomy enteroenterostomy Roux

limb stump staple line Can lead to peritonitis sepsis possible death Presentation

Tachycardia tachypnea Fever Ab painback pain Pelvic pressure or rebound tenderness

Anastamosis Leaks

Order Gastrograffin upper GI series Subclinical cases

Bowel rest Parenteral nutrition IV antibiotic if H pylori

Clinically suspect leak Laparoscopic evaluation and leak repair

Failure to evaluate is the most common cause of preventable major long-term disability or death in bariatric surgical patients

Pulmonary Embolism

Sudden cause of death up to one month after surgery 20-30 mortality rate High risk may have vena cava filter placement prior to surgery Prophylaxis with compression stockings and LMWH Early ambulation imperitive

Pulmonary Embolism

Presentation Profound hypoxia Hypotension Signs of sepsis

Immediate spiral chest CT Abdominal exploration if too large for machine No pathology start anticoagulation Too largehelliphellipNO SURGERY

Cholelithiasis

Up to 36 of patients within 6 months post-op Bile stasis leads to increased sludge and gallstones Prophylactic cholecystectomy prior to surgery if

evidence of existing sludge or stones Prevent post-operative disease with concurrent bariatric

surgery and cholecystectomy Prophylactic use of urosidol

Expensive and unpalatable

Stomal Ulceration

12-15 within 2-4 mos Post-surgery Etiology

Overabundant acid in pouch leads to excessive acid passing through stoma

Pouch tension and staple line breakdown NSAID use

Presentation Dyspepsia vomiting Epigastric or retrosternal pain

Stomal Ulceration

Treatment PPI carafate Antibiotics if H Pylori Avoid NSAIDS alcohol smoking

If no response to treatment Endoscopy Back to surgery for pouch revision or staple line repair

Dumping Syndrome

More than 15 patients Hypotention Tachycardia Lightheadedness syncope Flushing Abdominal cramping and diarrhea Nausea and vomiting

Dumping Syndrome

Occurs with high dose simple sugar ingestion Sugar in small intestine causes osmotic overload and fluid

shift from blood to intestine Increased intestinal volume leads to watery diarrhea Decreased blood volume leads to systemic changes Patient education

Eat slowly Avoid drinking before during and not until 30 minutes after meals

Constipation

Most common complaint Causes

Dehydration and decreased fluid intake post-operatively Increased metabolic water needs Calcium and iron supplement use following surgery

Treat with increased fluids and stool softeners

Nutritional Consequences

Iron deficiency anemia B12 deficiency Folate deficiency Calcium and Vitamin D deficiency

Not seen with purely restrictive surgeries

Iron deficiency and anemia

Common following RYGB As high as 49 of patients Multifactorial cause

Low gastric acid levels prohibit iron cleavage from food Absorption inhibited because no nutrient exposure to duodenum or

proximal jejunum Decrease in iron-rich food consumption due to intolerance

Treat with oral supplementation of ferrous sulfate or ferrous gluconate

Vitamin B12 deficiency

Up to 70 of patients Lack of hydrochloric acid and pepsin in stomach

Prevents B12 cleavage from food Affects secretion of intrinsic factor thus B12 absorption

Intolerance to meat and milk Oral supplementation usually adequate otherwise IM injections used

Folate Deficiency

40 of gastric bypass patients Complete absorption requires B12 Absorption dependent on HCl and upper 13 stomach Deficiency generally caused by decreased consumption Oral supplementation

Vitamin D and Calcium Deficiency

Vitamin D deficiency is common among obese people Calcium absorption decreased because duodenum is

bypassed Intolerance to dairy foods high in calcium Vitamin D is required for Ca++ absorption Prolonged deficiencies lead to

Bone resorption osteomalacia osteoporosis Treat with calcium citrate supplementation and 2 weekly

doses of Vitamin D

Nutritional Implications of Various Bariatric Surgeries(34)

bull RYGB Malabsorption of Vit B12 Vit B1 (thiamin) Vit D Vit K Folate Iron Calcium

bull LAGB Folic Acid deficiency

bull BPD and BPDDS Vit A D E and K deficiency Protein-Calorie Malnutrition Malabsorption of

Calcium Zinc Selenium Sodium Potassium Chloride Phosphorus Magnesium

Recommended Daily Supplements(4)

Multivitamin with iron (prenatal vitamin will have adeq amount of folic acid)

Calcium (citrate) with vitamin D (1200-1500 mg calcium with 800-1000 IU vitamin D)

Oral vitamin B12 (500-1000 mcg) Iron (65 mgday in elemental form)

Vitamin C (to increase absorption of Iron) Thiamin (10 mgday)

Diet Recommendations(3)

Reduce food volume Chew food very well Slow pace of eating No liquids with meals Encourage fruits and vegetables as diet progresses Include high protein foods (at least 60gday) may need protein

supplements

Diet Progression Gastric Bypass

Stage 1 Clear liquids and protein supplement (1 week)

Stage 2No concentrated sweets low fat puree diet ( 3 weeks)

Stage 3 Regular texture weight reduction diet

Diet Progression Lap - Band

Stage 1 Clear liquids and protein supplement ( 2 weeks)

Stage 2 No concentrated sweets low fat puree diet (2weeks)

Stage 3 Regular texture weight reduction diet

Stage 1

Only clear liquids allowed Avoid sweetened beverages Sip very slowly No straws Avoid caffeinated carbonated and alcoholic beverages STOP drinking if you feel fullness pain or discomfort

Protein supplements

Begin the day after you go home from Hospital

Minimum protein target 70gmsday

May use powder or pre-mixed liquid forms (Whey protein is preferred)

Protein pills may not be used

Vitamin and Mineral Supplements

Gastric bypass patients In addition to eating much less food gastric bypass patients will also

absorb vitamins and minerals differently after surgery They will require daily multivitamin calcium and iron

supplementation for the rest of your life

Vitamin and Mineral Supplements

Lap-Bandreg patients

Require a multivitamin with minerals daily

It may be necessary to take additional vitamins and minerals eg calcium iron folateB1 B12These will be prescribed as needed

Stage 2 dietPUREE

Puree diet

Regular scheduled meals Avoid meal skipping Plan meals in advance Eat Slowly Eat protein foods first Moisten meats Use liquid protein as supplement not as meal replacement

Measure 2 oz portions at each meal eating when full Separate liquids and solids No bread rice or pasta Avoid added sugars and high fat

foods VARIETY

Anastamosis Leaks

Up to 7-10 days after surgery Most common at gastrojejunostomy enteroenterostomy Roux

limb stump staple line Can lead to peritonitis sepsis possible death Presentation

Tachycardia tachypnea Fever Ab painback pain Pelvic pressure or rebound tenderness

Anastamosis Leaks

Order Gastrograffin upper GI series Subclinical cases

Bowel rest Parenteral nutrition IV antibiotic if H pylori

Clinically suspect leak Laparoscopic evaluation and leak repair

Failure to evaluate is the most common cause of preventable major long-term disability or death in bariatric surgical patients

Pulmonary Embolism

Sudden cause of death up to one month after surgery 20-30 mortality rate High risk may have vena cava filter placement prior to surgery Prophylaxis with compression stockings and LMWH Early ambulation imperitive

Pulmonary Embolism

Presentation Profound hypoxia Hypotension Signs of sepsis

Immediate spiral chest CT Abdominal exploration if too large for machine No pathology start anticoagulation Too largehelliphellipNO SURGERY

Cholelithiasis

Up to 36 of patients within 6 months post-op Bile stasis leads to increased sludge and gallstones Prophylactic cholecystectomy prior to surgery if

evidence of existing sludge or stones Prevent post-operative disease with concurrent bariatric

surgery and cholecystectomy Prophylactic use of urosidol

Expensive and unpalatable

Stomal Ulceration

12-15 within 2-4 mos Post-surgery Etiology

Overabundant acid in pouch leads to excessive acid passing through stoma

Pouch tension and staple line breakdown NSAID use

Presentation Dyspepsia vomiting Epigastric or retrosternal pain

Stomal Ulceration

Treatment PPI carafate Antibiotics if H Pylori Avoid NSAIDS alcohol smoking

If no response to treatment Endoscopy Back to surgery for pouch revision or staple line repair

Dumping Syndrome

More than 15 patients Hypotention Tachycardia Lightheadedness syncope Flushing Abdominal cramping and diarrhea Nausea and vomiting

Dumping Syndrome

Occurs with high dose simple sugar ingestion Sugar in small intestine causes osmotic overload and fluid

shift from blood to intestine Increased intestinal volume leads to watery diarrhea Decreased blood volume leads to systemic changes Patient education

Eat slowly Avoid drinking before during and not until 30 minutes after meals

Constipation

Most common complaint Causes

Dehydration and decreased fluid intake post-operatively Increased metabolic water needs Calcium and iron supplement use following surgery

Treat with increased fluids and stool softeners

Nutritional Consequences

Iron deficiency anemia B12 deficiency Folate deficiency Calcium and Vitamin D deficiency

Not seen with purely restrictive surgeries

Iron deficiency and anemia

Common following RYGB As high as 49 of patients Multifactorial cause

Low gastric acid levels prohibit iron cleavage from food Absorption inhibited because no nutrient exposure to duodenum or

proximal jejunum Decrease in iron-rich food consumption due to intolerance

Treat with oral supplementation of ferrous sulfate or ferrous gluconate

Vitamin B12 deficiency

Up to 70 of patients Lack of hydrochloric acid and pepsin in stomach

Prevents B12 cleavage from food Affects secretion of intrinsic factor thus B12 absorption

Intolerance to meat and milk Oral supplementation usually adequate otherwise IM injections used

Folate Deficiency

40 of gastric bypass patients Complete absorption requires B12 Absorption dependent on HCl and upper 13 stomach Deficiency generally caused by decreased consumption Oral supplementation

Vitamin D and Calcium Deficiency

Vitamin D deficiency is common among obese people Calcium absorption decreased because duodenum is

bypassed Intolerance to dairy foods high in calcium Vitamin D is required for Ca++ absorption Prolonged deficiencies lead to

Bone resorption osteomalacia osteoporosis Treat with calcium citrate supplementation and 2 weekly

doses of Vitamin D

Nutritional Implications of Various Bariatric Surgeries(34)

bull RYGB Malabsorption of Vit B12 Vit B1 (thiamin) Vit D Vit K Folate Iron Calcium

bull LAGB Folic Acid deficiency

bull BPD and BPDDS Vit A D E and K deficiency Protein-Calorie Malnutrition Malabsorption of

Calcium Zinc Selenium Sodium Potassium Chloride Phosphorus Magnesium

Recommended Daily Supplements(4)

Multivitamin with iron (prenatal vitamin will have adeq amount of folic acid)

Calcium (citrate) with vitamin D (1200-1500 mg calcium with 800-1000 IU vitamin D)

Oral vitamin B12 (500-1000 mcg) Iron (65 mgday in elemental form)

Vitamin C (to increase absorption of Iron) Thiamin (10 mgday)

Diet Recommendations(3)

Reduce food volume Chew food very well Slow pace of eating No liquids with meals Encourage fruits and vegetables as diet progresses Include high protein foods (at least 60gday) may need protein

supplements

Diet Progression Gastric Bypass

Stage 1 Clear liquids and protein supplement (1 week)

Stage 2No concentrated sweets low fat puree diet ( 3 weeks)

Stage 3 Regular texture weight reduction diet

Diet Progression Lap - Band

Stage 1 Clear liquids and protein supplement ( 2 weeks)

Stage 2 No concentrated sweets low fat puree diet (2weeks)

Stage 3 Regular texture weight reduction diet

Stage 1

Only clear liquids allowed Avoid sweetened beverages Sip very slowly No straws Avoid caffeinated carbonated and alcoholic beverages STOP drinking if you feel fullness pain or discomfort

Protein supplements

Begin the day after you go home from Hospital

Minimum protein target 70gmsday

May use powder or pre-mixed liquid forms (Whey protein is preferred)

Protein pills may not be used

Vitamin and Mineral Supplements

Gastric bypass patients In addition to eating much less food gastric bypass patients will also

absorb vitamins and minerals differently after surgery They will require daily multivitamin calcium and iron

supplementation for the rest of your life

Vitamin and Mineral Supplements

Lap-Bandreg patients

Require a multivitamin with minerals daily

It may be necessary to take additional vitamins and minerals eg calcium iron folateB1 B12These will be prescribed as needed

Stage 2 dietPUREE

Puree diet

Regular scheduled meals Avoid meal skipping Plan meals in advance Eat Slowly Eat protein foods first Moisten meats Use liquid protein as supplement not as meal replacement

Measure 2 oz portions at each meal eating when full Separate liquids and solids No bread rice or pasta Avoid added sugars and high fat

foods VARIETY

Anastamosis Leaks

Order Gastrograffin upper GI series Subclinical cases

Bowel rest Parenteral nutrition IV antibiotic if H pylori

Clinically suspect leak Laparoscopic evaluation and leak repair

Failure to evaluate is the most common cause of preventable major long-term disability or death in bariatric surgical patients

Pulmonary Embolism

Sudden cause of death up to one month after surgery 20-30 mortality rate High risk may have vena cava filter placement prior to surgery Prophylaxis with compression stockings and LMWH Early ambulation imperitive

Pulmonary Embolism

Presentation Profound hypoxia Hypotension Signs of sepsis

Immediate spiral chest CT Abdominal exploration if too large for machine No pathology start anticoagulation Too largehelliphellipNO SURGERY

Cholelithiasis

Up to 36 of patients within 6 months post-op Bile stasis leads to increased sludge and gallstones Prophylactic cholecystectomy prior to surgery if

evidence of existing sludge or stones Prevent post-operative disease with concurrent bariatric

surgery and cholecystectomy Prophylactic use of urosidol

Expensive and unpalatable

Stomal Ulceration

12-15 within 2-4 mos Post-surgery Etiology

Overabundant acid in pouch leads to excessive acid passing through stoma

Pouch tension and staple line breakdown NSAID use

Presentation Dyspepsia vomiting Epigastric or retrosternal pain

Stomal Ulceration

Treatment PPI carafate Antibiotics if H Pylori Avoid NSAIDS alcohol smoking

If no response to treatment Endoscopy Back to surgery for pouch revision or staple line repair

Dumping Syndrome

More than 15 patients Hypotention Tachycardia Lightheadedness syncope Flushing Abdominal cramping and diarrhea Nausea and vomiting

Dumping Syndrome

Occurs with high dose simple sugar ingestion Sugar in small intestine causes osmotic overload and fluid

shift from blood to intestine Increased intestinal volume leads to watery diarrhea Decreased blood volume leads to systemic changes Patient education

Eat slowly Avoid drinking before during and not until 30 minutes after meals

Constipation

Most common complaint Causes

Dehydration and decreased fluid intake post-operatively Increased metabolic water needs Calcium and iron supplement use following surgery

Treat with increased fluids and stool softeners

Nutritional Consequences

Iron deficiency anemia B12 deficiency Folate deficiency Calcium and Vitamin D deficiency

Not seen with purely restrictive surgeries

Iron deficiency and anemia

Common following RYGB As high as 49 of patients Multifactorial cause

Low gastric acid levels prohibit iron cleavage from food Absorption inhibited because no nutrient exposure to duodenum or

proximal jejunum Decrease in iron-rich food consumption due to intolerance

Treat with oral supplementation of ferrous sulfate or ferrous gluconate

Vitamin B12 deficiency

Up to 70 of patients Lack of hydrochloric acid and pepsin in stomach

Prevents B12 cleavage from food Affects secretion of intrinsic factor thus B12 absorption

Intolerance to meat and milk Oral supplementation usually adequate otherwise IM injections used

Folate Deficiency

40 of gastric bypass patients Complete absorption requires B12 Absorption dependent on HCl and upper 13 stomach Deficiency generally caused by decreased consumption Oral supplementation

Vitamin D and Calcium Deficiency

Vitamin D deficiency is common among obese people Calcium absorption decreased because duodenum is

bypassed Intolerance to dairy foods high in calcium Vitamin D is required for Ca++ absorption Prolonged deficiencies lead to

Bone resorption osteomalacia osteoporosis Treat with calcium citrate supplementation and 2 weekly

doses of Vitamin D

Nutritional Implications of Various Bariatric Surgeries(34)

bull RYGB Malabsorption of Vit B12 Vit B1 (thiamin) Vit D Vit K Folate Iron Calcium

bull LAGB Folic Acid deficiency

bull BPD and BPDDS Vit A D E and K deficiency Protein-Calorie Malnutrition Malabsorption of

Calcium Zinc Selenium Sodium Potassium Chloride Phosphorus Magnesium

Recommended Daily Supplements(4)

Multivitamin with iron (prenatal vitamin will have adeq amount of folic acid)

Calcium (citrate) with vitamin D (1200-1500 mg calcium with 800-1000 IU vitamin D)

Oral vitamin B12 (500-1000 mcg) Iron (65 mgday in elemental form)

Vitamin C (to increase absorption of Iron) Thiamin (10 mgday)

Diet Recommendations(3)

Reduce food volume Chew food very well Slow pace of eating No liquids with meals Encourage fruits and vegetables as diet progresses Include high protein foods (at least 60gday) may need protein

supplements

Diet Progression Gastric Bypass

Stage 1 Clear liquids and protein supplement (1 week)

Stage 2No concentrated sweets low fat puree diet ( 3 weeks)

Stage 3 Regular texture weight reduction diet

Diet Progression Lap - Band

Stage 1 Clear liquids and protein supplement ( 2 weeks)

Stage 2 No concentrated sweets low fat puree diet (2weeks)

Stage 3 Regular texture weight reduction diet

Stage 1

Only clear liquids allowed Avoid sweetened beverages Sip very slowly No straws Avoid caffeinated carbonated and alcoholic beverages STOP drinking if you feel fullness pain or discomfort

Protein supplements

Begin the day after you go home from Hospital

Minimum protein target 70gmsday

May use powder or pre-mixed liquid forms (Whey protein is preferred)

Protein pills may not be used

Vitamin and Mineral Supplements

Gastric bypass patients In addition to eating much less food gastric bypass patients will also

absorb vitamins and minerals differently after surgery They will require daily multivitamin calcium and iron

supplementation for the rest of your life

Vitamin and Mineral Supplements

Lap-Bandreg patients

Require a multivitamin with minerals daily

It may be necessary to take additional vitamins and minerals eg calcium iron folateB1 B12These will be prescribed as needed

Stage 2 dietPUREE

Puree diet

Regular scheduled meals Avoid meal skipping Plan meals in advance Eat Slowly Eat protein foods first Moisten meats Use liquid protein as supplement not as meal replacement

Measure 2 oz portions at each meal eating when full Separate liquids and solids No bread rice or pasta Avoid added sugars and high fat

foods VARIETY

Pulmonary Embolism

Sudden cause of death up to one month after surgery 20-30 mortality rate High risk may have vena cava filter placement prior to surgery Prophylaxis with compression stockings and LMWH Early ambulation imperitive

Pulmonary Embolism

Presentation Profound hypoxia Hypotension Signs of sepsis

Immediate spiral chest CT Abdominal exploration if too large for machine No pathology start anticoagulation Too largehelliphellipNO SURGERY

Cholelithiasis

Up to 36 of patients within 6 months post-op Bile stasis leads to increased sludge and gallstones Prophylactic cholecystectomy prior to surgery if

evidence of existing sludge or stones Prevent post-operative disease with concurrent bariatric

surgery and cholecystectomy Prophylactic use of urosidol

Expensive and unpalatable

Stomal Ulceration

12-15 within 2-4 mos Post-surgery Etiology

Overabundant acid in pouch leads to excessive acid passing through stoma

Pouch tension and staple line breakdown NSAID use

Presentation Dyspepsia vomiting Epigastric or retrosternal pain

Stomal Ulceration

Treatment PPI carafate Antibiotics if H Pylori Avoid NSAIDS alcohol smoking

If no response to treatment Endoscopy Back to surgery for pouch revision or staple line repair

Dumping Syndrome

More than 15 patients Hypotention Tachycardia Lightheadedness syncope Flushing Abdominal cramping and diarrhea Nausea and vomiting

Dumping Syndrome

Occurs with high dose simple sugar ingestion Sugar in small intestine causes osmotic overload and fluid

shift from blood to intestine Increased intestinal volume leads to watery diarrhea Decreased blood volume leads to systemic changes Patient education

Eat slowly Avoid drinking before during and not until 30 minutes after meals

Constipation

Most common complaint Causes

Dehydration and decreased fluid intake post-operatively Increased metabolic water needs Calcium and iron supplement use following surgery

Treat with increased fluids and stool softeners

Nutritional Consequences

Iron deficiency anemia B12 deficiency Folate deficiency Calcium and Vitamin D deficiency

Not seen with purely restrictive surgeries

Iron deficiency and anemia

Common following RYGB As high as 49 of patients Multifactorial cause

Low gastric acid levels prohibit iron cleavage from food Absorption inhibited because no nutrient exposure to duodenum or

proximal jejunum Decrease in iron-rich food consumption due to intolerance

Treat with oral supplementation of ferrous sulfate or ferrous gluconate

Vitamin B12 deficiency

Up to 70 of patients Lack of hydrochloric acid and pepsin in stomach

Prevents B12 cleavage from food Affects secretion of intrinsic factor thus B12 absorption

Intolerance to meat and milk Oral supplementation usually adequate otherwise IM injections used

Folate Deficiency

40 of gastric bypass patients Complete absorption requires B12 Absorption dependent on HCl and upper 13 stomach Deficiency generally caused by decreased consumption Oral supplementation

Vitamin D and Calcium Deficiency

Vitamin D deficiency is common among obese people Calcium absorption decreased because duodenum is

bypassed Intolerance to dairy foods high in calcium Vitamin D is required for Ca++ absorption Prolonged deficiencies lead to

Bone resorption osteomalacia osteoporosis Treat with calcium citrate supplementation and 2 weekly

doses of Vitamin D

Nutritional Implications of Various Bariatric Surgeries(34)

bull RYGB Malabsorption of Vit B12 Vit B1 (thiamin) Vit D Vit K Folate Iron Calcium

bull LAGB Folic Acid deficiency

bull BPD and BPDDS Vit A D E and K deficiency Protein-Calorie Malnutrition Malabsorption of

Calcium Zinc Selenium Sodium Potassium Chloride Phosphorus Magnesium

Recommended Daily Supplements(4)

Multivitamin with iron (prenatal vitamin will have adeq amount of folic acid)

Calcium (citrate) with vitamin D (1200-1500 mg calcium with 800-1000 IU vitamin D)

Oral vitamin B12 (500-1000 mcg) Iron (65 mgday in elemental form)

Vitamin C (to increase absorption of Iron) Thiamin (10 mgday)

Diet Recommendations(3)

Reduce food volume Chew food very well Slow pace of eating No liquids with meals Encourage fruits and vegetables as diet progresses Include high protein foods (at least 60gday) may need protein

supplements

Diet Progression Gastric Bypass

Stage 1 Clear liquids and protein supplement (1 week)

Stage 2No concentrated sweets low fat puree diet ( 3 weeks)

Stage 3 Regular texture weight reduction diet

Diet Progression Lap - Band

Stage 1 Clear liquids and protein supplement ( 2 weeks)

Stage 2 No concentrated sweets low fat puree diet (2weeks)

Stage 3 Regular texture weight reduction diet

Stage 1

Only clear liquids allowed Avoid sweetened beverages Sip very slowly No straws Avoid caffeinated carbonated and alcoholic beverages STOP drinking if you feel fullness pain or discomfort

Protein supplements

Begin the day after you go home from Hospital

Minimum protein target 70gmsday

May use powder or pre-mixed liquid forms (Whey protein is preferred)

Protein pills may not be used

Vitamin and Mineral Supplements

Gastric bypass patients In addition to eating much less food gastric bypass patients will also

absorb vitamins and minerals differently after surgery They will require daily multivitamin calcium and iron

supplementation for the rest of your life

Vitamin and Mineral Supplements

Lap-Bandreg patients

Require a multivitamin with minerals daily

It may be necessary to take additional vitamins and minerals eg calcium iron folateB1 B12These will be prescribed as needed

Stage 2 dietPUREE

Puree diet

Regular scheduled meals Avoid meal skipping Plan meals in advance Eat Slowly Eat protein foods first Moisten meats Use liquid protein as supplement not as meal replacement

Measure 2 oz portions at each meal eating when full Separate liquids and solids No bread rice or pasta Avoid added sugars and high fat

foods VARIETY

Pulmonary Embolism

Presentation Profound hypoxia Hypotension Signs of sepsis

Immediate spiral chest CT Abdominal exploration if too large for machine No pathology start anticoagulation Too largehelliphellipNO SURGERY

Cholelithiasis

Up to 36 of patients within 6 months post-op Bile stasis leads to increased sludge and gallstones Prophylactic cholecystectomy prior to surgery if

evidence of existing sludge or stones Prevent post-operative disease with concurrent bariatric

surgery and cholecystectomy Prophylactic use of urosidol

Expensive and unpalatable

Stomal Ulceration

12-15 within 2-4 mos Post-surgery Etiology

Overabundant acid in pouch leads to excessive acid passing through stoma

Pouch tension and staple line breakdown NSAID use

Presentation Dyspepsia vomiting Epigastric or retrosternal pain

Stomal Ulceration

Treatment PPI carafate Antibiotics if H Pylori Avoid NSAIDS alcohol smoking

If no response to treatment Endoscopy Back to surgery for pouch revision or staple line repair

Dumping Syndrome

More than 15 patients Hypotention Tachycardia Lightheadedness syncope Flushing Abdominal cramping and diarrhea Nausea and vomiting

Dumping Syndrome

Occurs with high dose simple sugar ingestion Sugar in small intestine causes osmotic overload and fluid

shift from blood to intestine Increased intestinal volume leads to watery diarrhea Decreased blood volume leads to systemic changes Patient education

Eat slowly Avoid drinking before during and not until 30 minutes after meals

Constipation

Most common complaint Causes

Dehydration and decreased fluid intake post-operatively Increased metabolic water needs Calcium and iron supplement use following surgery

Treat with increased fluids and stool softeners

Nutritional Consequences

Iron deficiency anemia B12 deficiency Folate deficiency Calcium and Vitamin D deficiency

Not seen with purely restrictive surgeries

Iron deficiency and anemia

Common following RYGB As high as 49 of patients Multifactorial cause

Low gastric acid levels prohibit iron cleavage from food Absorption inhibited because no nutrient exposure to duodenum or

proximal jejunum Decrease in iron-rich food consumption due to intolerance

Treat with oral supplementation of ferrous sulfate or ferrous gluconate

Vitamin B12 deficiency

Up to 70 of patients Lack of hydrochloric acid and pepsin in stomach

Prevents B12 cleavage from food Affects secretion of intrinsic factor thus B12 absorption

Intolerance to meat and milk Oral supplementation usually adequate otherwise IM injections used

Folate Deficiency

40 of gastric bypass patients Complete absorption requires B12 Absorption dependent on HCl and upper 13 stomach Deficiency generally caused by decreased consumption Oral supplementation

Vitamin D and Calcium Deficiency

Vitamin D deficiency is common among obese people Calcium absorption decreased because duodenum is

bypassed Intolerance to dairy foods high in calcium Vitamin D is required for Ca++ absorption Prolonged deficiencies lead to

Bone resorption osteomalacia osteoporosis Treat with calcium citrate supplementation and 2 weekly

doses of Vitamin D

Nutritional Implications of Various Bariatric Surgeries(34)

bull RYGB Malabsorption of Vit B12 Vit B1 (thiamin) Vit D Vit K Folate Iron Calcium

bull LAGB Folic Acid deficiency

bull BPD and BPDDS Vit A D E and K deficiency Protein-Calorie Malnutrition Malabsorption of

Calcium Zinc Selenium Sodium Potassium Chloride Phosphorus Magnesium

Recommended Daily Supplements(4)

Multivitamin with iron (prenatal vitamin will have adeq amount of folic acid)

Calcium (citrate) with vitamin D (1200-1500 mg calcium with 800-1000 IU vitamin D)

Oral vitamin B12 (500-1000 mcg) Iron (65 mgday in elemental form)

Vitamin C (to increase absorption of Iron) Thiamin (10 mgday)

Diet Recommendations(3)

Reduce food volume Chew food very well Slow pace of eating No liquids with meals Encourage fruits and vegetables as diet progresses Include high protein foods (at least 60gday) may need protein

supplements

Diet Progression Gastric Bypass

Stage 1 Clear liquids and protein supplement (1 week)

Stage 2No concentrated sweets low fat puree diet ( 3 weeks)

Stage 3 Regular texture weight reduction diet

Diet Progression Lap - Band

Stage 1 Clear liquids and protein supplement ( 2 weeks)

Stage 2 No concentrated sweets low fat puree diet (2weeks)

Stage 3 Regular texture weight reduction diet

Stage 1

Only clear liquids allowed Avoid sweetened beverages Sip very slowly No straws Avoid caffeinated carbonated and alcoholic beverages STOP drinking if you feel fullness pain or discomfort

Protein supplements

Begin the day after you go home from Hospital

Minimum protein target 70gmsday

May use powder or pre-mixed liquid forms (Whey protein is preferred)

Protein pills may not be used

Vitamin and Mineral Supplements

Gastric bypass patients In addition to eating much less food gastric bypass patients will also

absorb vitamins and minerals differently after surgery They will require daily multivitamin calcium and iron

supplementation for the rest of your life

Vitamin and Mineral Supplements

Lap-Bandreg patients

Require a multivitamin with minerals daily

It may be necessary to take additional vitamins and minerals eg calcium iron folateB1 B12These will be prescribed as needed

Stage 2 dietPUREE

Puree diet

Regular scheduled meals Avoid meal skipping Plan meals in advance Eat Slowly Eat protein foods first Moisten meats Use liquid protein as supplement not as meal replacement

Measure 2 oz portions at each meal eating when full Separate liquids and solids No bread rice or pasta Avoid added sugars and high fat

foods VARIETY

Cholelithiasis

Up to 36 of patients within 6 months post-op Bile stasis leads to increased sludge and gallstones Prophylactic cholecystectomy prior to surgery if

evidence of existing sludge or stones Prevent post-operative disease with concurrent bariatric

surgery and cholecystectomy Prophylactic use of urosidol

Expensive and unpalatable

Stomal Ulceration

12-15 within 2-4 mos Post-surgery Etiology

Overabundant acid in pouch leads to excessive acid passing through stoma

Pouch tension and staple line breakdown NSAID use

Presentation Dyspepsia vomiting Epigastric or retrosternal pain

Stomal Ulceration

Treatment PPI carafate Antibiotics if H Pylori Avoid NSAIDS alcohol smoking

If no response to treatment Endoscopy Back to surgery for pouch revision or staple line repair

Dumping Syndrome

More than 15 patients Hypotention Tachycardia Lightheadedness syncope Flushing Abdominal cramping and diarrhea Nausea and vomiting

Dumping Syndrome

Occurs with high dose simple sugar ingestion Sugar in small intestine causes osmotic overload and fluid

shift from blood to intestine Increased intestinal volume leads to watery diarrhea Decreased blood volume leads to systemic changes Patient education

Eat slowly Avoid drinking before during and not until 30 minutes after meals

Constipation

Most common complaint Causes

Dehydration and decreased fluid intake post-operatively Increased metabolic water needs Calcium and iron supplement use following surgery

Treat with increased fluids and stool softeners

Nutritional Consequences

Iron deficiency anemia B12 deficiency Folate deficiency Calcium and Vitamin D deficiency

Not seen with purely restrictive surgeries

Iron deficiency and anemia

Common following RYGB As high as 49 of patients Multifactorial cause

Low gastric acid levels prohibit iron cleavage from food Absorption inhibited because no nutrient exposure to duodenum or

proximal jejunum Decrease in iron-rich food consumption due to intolerance

Treat with oral supplementation of ferrous sulfate or ferrous gluconate

Vitamin B12 deficiency

Up to 70 of patients Lack of hydrochloric acid and pepsin in stomach

Prevents B12 cleavage from food Affects secretion of intrinsic factor thus B12 absorption

Intolerance to meat and milk Oral supplementation usually adequate otherwise IM injections used

Folate Deficiency

40 of gastric bypass patients Complete absorption requires B12 Absorption dependent on HCl and upper 13 stomach Deficiency generally caused by decreased consumption Oral supplementation

Vitamin D and Calcium Deficiency

Vitamin D deficiency is common among obese people Calcium absorption decreased because duodenum is

bypassed Intolerance to dairy foods high in calcium Vitamin D is required for Ca++ absorption Prolonged deficiencies lead to

Bone resorption osteomalacia osteoporosis Treat with calcium citrate supplementation and 2 weekly

doses of Vitamin D

Nutritional Implications of Various Bariatric Surgeries(34)

bull RYGB Malabsorption of Vit B12 Vit B1 (thiamin) Vit D Vit K Folate Iron Calcium

bull LAGB Folic Acid deficiency

bull BPD and BPDDS Vit A D E and K deficiency Protein-Calorie Malnutrition Malabsorption of

Calcium Zinc Selenium Sodium Potassium Chloride Phosphorus Magnesium

Recommended Daily Supplements(4)

Multivitamin with iron (prenatal vitamin will have adeq amount of folic acid)

Calcium (citrate) with vitamin D (1200-1500 mg calcium with 800-1000 IU vitamin D)

Oral vitamin B12 (500-1000 mcg) Iron (65 mgday in elemental form)

Vitamin C (to increase absorption of Iron) Thiamin (10 mgday)

Diet Recommendations(3)

Reduce food volume Chew food very well Slow pace of eating No liquids with meals Encourage fruits and vegetables as diet progresses Include high protein foods (at least 60gday) may need protein

supplements

Diet Progression Gastric Bypass

Stage 1 Clear liquids and protein supplement (1 week)

Stage 2No concentrated sweets low fat puree diet ( 3 weeks)

Stage 3 Regular texture weight reduction diet

Diet Progression Lap - Band

Stage 1 Clear liquids and protein supplement ( 2 weeks)

Stage 2 No concentrated sweets low fat puree diet (2weeks)

Stage 3 Regular texture weight reduction diet

Stage 1

Only clear liquids allowed Avoid sweetened beverages Sip very slowly No straws Avoid caffeinated carbonated and alcoholic beverages STOP drinking if you feel fullness pain or discomfort

Protein supplements

Begin the day after you go home from Hospital

Minimum protein target 70gmsday

May use powder or pre-mixed liquid forms (Whey protein is preferred)

Protein pills may not be used

Vitamin and Mineral Supplements

Gastric bypass patients In addition to eating much less food gastric bypass patients will also

absorb vitamins and minerals differently after surgery They will require daily multivitamin calcium and iron

supplementation for the rest of your life

Vitamin and Mineral Supplements

Lap-Bandreg patients

Require a multivitamin with minerals daily

It may be necessary to take additional vitamins and minerals eg calcium iron folateB1 B12These will be prescribed as needed

Stage 2 dietPUREE

Puree diet

Regular scheduled meals Avoid meal skipping Plan meals in advance Eat Slowly Eat protein foods first Moisten meats Use liquid protein as supplement not as meal replacement

Measure 2 oz portions at each meal eating when full Separate liquids and solids No bread rice or pasta Avoid added sugars and high fat

foods VARIETY

Stomal Ulceration

12-15 within 2-4 mos Post-surgery Etiology

Overabundant acid in pouch leads to excessive acid passing through stoma

Pouch tension and staple line breakdown NSAID use

Presentation Dyspepsia vomiting Epigastric or retrosternal pain

Stomal Ulceration

Treatment PPI carafate Antibiotics if H Pylori Avoid NSAIDS alcohol smoking

If no response to treatment Endoscopy Back to surgery for pouch revision or staple line repair

Dumping Syndrome

More than 15 patients Hypotention Tachycardia Lightheadedness syncope Flushing Abdominal cramping and diarrhea Nausea and vomiting

Dumping Syndrome

Occurs with high dose simple sugar ingestion Sugar in small intestine causes osmotic overload and fluid

shift from blood to intestine Increased intestinal volume leads to watery diarrhea Decreased blood volume leads to systemic changes Patient education

Eat slowly Avoid drinking before during and not until 30 minutes after meals

Constipation

Most common complaint Causes

Dehydration and decreased fluid intake post-operatively Increased metabolic water needs Calcium and iron supplement use following surgery

Treat with increased fluids and stool softeners

Nutritional Consequences

Iron deficiency anemia B12 deficiency Folate deficiency Calcium and Vitamin D deficiency

Not seen with purely restrictive surgeries

Iron deficiency and anemia

Common following RYGB As high as 49 of patients Multifactorial cause

Low gastric acid levels prohibit iron cleavage from food Absorption inhibited because no nutrient exposure to duodenum or

proximal jejunum Decrease in iron-rich food consumption due to intolerance

Treat with oral supplementation of ferrous sulfate or ferrous gluconate

Vitamin B12 deficiency

Up to 70 of patients Lack of hydrochloric acid and pepsin in stomach

Prevents B12 cleavage from food Affects secretion of intrinsic factor thus B12 absorption

Intolerance to meat and milk Oral supplementation usually adequate otherwise IM injections used

Folate Deficiency

40 of gastric bypass patients Complete absorption requires B12 Absorption dependent on HCl and upper 13 stomach Deficiency generally caused by decreased consumption Oral supplementation

Vitamin D and Calcium Deficiency

Vitamin D deficiency is common among obese people Calcium absorption decreased because duodenum is

bypassed Intolerance to dairy foods high in calcium Vitamin D is required for Ca++ absorption Prolonged deficiencies lead to

Bone resorption osteomalacia osteoporosis Treat with calcium citrate supplementation and 2 weekly

doses of Vitamin D

Nutritional Implications of Various Bariatric Surgeries(34)

bull RYGB Malabsorption of Vit B12 Vit B1 (thiamin) Vit D Vit K Folate Iron Calcium

bull LAGB Folic Acid deficiency

bull BPD and BPDDS Vit A D E and K deficiency Protein-Calorie Malnutrition Malabsorption of

Calcium Zinc Selenium Sodium Potassium Chloride Phosphorus Magnesium

Recommended Daily Supplements(4)

Multivitamin with iron (prenatal vitamin will have adeq amount of folic acid)

Calcium (citrate) with vitamin D (1200-1500 mg calcium with 800-1000 IU vitamin D)

Oral vitamin B12 (500-1000 mcg) Iron (65 mgday in elemental form)

Vitamin C (to increase absorption of Iron) Thiamin (10 mgday)

Diet Recommendations(3)

Reduce food volume Chew food very well Slow pace of eating No liquids with meals Encourage fruits and vegetables as diet progresses Include high protein foods (at least 60gday) may need protein

supplements

Diet Progression Gastric Bypass

Stage 1 Clear liquids and protein supplement (1 week)

Stage 2No concentrated sweets low fat puree diet ( 3 weeks)

Stage 3 Regular texture weight reduction diet

Diet Progression Lap - Band

Stage 1 Clear liquids and protein supplement ( 2 weeks)

Stage 2 No concentrated sweets low fat puree diet (2weeks)

Stage 3 Regular texture weight reduction diet

Stage 1

Only clear liquids allowed Avoid sweetened beverages Sip very slowly No straws Avoid caffeinated carbonated and alcoholic beverages STOP drinking if you feel fullness pain or discomfort

Protein supplements

Begin the day after you go home from Hospital

Minimum protein target 70gmsday

May use powder or pre-mixed liquid forms (Whey protein is preferred)

Protein pills may not be used

Vitamin and Mineral Supplements

Gastric bypass patients In addition to eating much less food gastric bypass patients will also

absorb vitamins and minerals differently after surgery They will require daily multivitamin calcium and iron

supplementation for the rest of your life

Vitamin and Mineral Supplements

Lap-Bandreg patients

Require a multivitamin with minerals daily

It may be necessary to take additional vitamins and minerals eg calcium iron folateB1 B12These will be prescribed as needed

Stage 2 dietPUREE

Puree diet

Regular scheduled meals Avoid meal skipping Plan meals in advance Eat Slowly Eat protein foods first Moisten meats Use liquid protein as supplement not as meal replacement

Measure 2 oz portions at each meal eating when full Separate liquids and solids No bread rice or pasta Avoid added sugars and high fat

foods VARIETY

Stomal Ulceration

Treatment PPI carafate Antibiotics if H Pylori Avoid NSAIDS alcohol smoking

If no response to treatment Endoscopy Back to surgery for pouch revision or staple line repair

Dumping Syndrome

More than 15 patients Hypotention Tachycardia Lightheadedness syncope Flushing Abdominal cramping and diarrhea Nausea and vomiting

Dumping Syndrome

Occurs with high dose simple sugar ingestion Sugar in small intestine causes osmotic overload and fluid

shift from blood to intestine Increased intestinal volume leads to watery diarrhea Decreased blood volume leads to systemic changes Patient education

Eat slowly Avoid drinking before during and not until 30 minutes after meals

Constipation

Most common complaint Causes

Dehydration and decreased fluid intake post-operatively Increased metabolic water needs Calcium and iron supplement use following surgery

Treat with increased fluids and stool softeners

Nutritional Consequences

Iron deficiency anemia B12 deficiency Folate deficiency Calcium and Vitamin D deficiency

Not seen with purely restrictive surgeries

Iron deficiency and anemia

Common following RYGB As high as 49 of patients Multifactorial cause

Low gastric acid levels prohibit iron cleavage from food Absorption inhibited because no nutrient exposure to duodenum or

proximal jejunum Decrease in iron-rich food consumption due to intolerance

Treat with oral supplementation of ferrous sulfate or ferrous gluconate

Vitamin B12 deficiency

Up to 70 of patients Lack of hydrochloric acid and pepsin in stomach

Prevents B12 cleavage from food Affects secretion of intrinsic factor thus B12 absorption

Intolerance to meat and milk Oral supplementation usually adequate otherwise IM injections used

Folate Deficiency

40 of gastric bypass patients Complete absorption requires B12 Absorption dependent on HCl and upper 13 stomach Deficiency generally caused by decreased consumption Oral supplementation

Vitamin D and Calcium Deficiency

Vitamin D deficiency is common among obese people Calcium absorption decreased because duodenum is

bypassed Intolerance to dairy foods high in calcium Vitamin D is required for Ca++ absorption Prolonged deficiencies lead to

Bone resorption osteomalacia osteoporosis Treat with calcium citrate supplementation and 2 weekly

doses of Vitamin D

Nutritional Implications of Various Bariatric Surgeries(34)

bull RYGB Malabsorption of Vit B12 Vit B1 (thiamin) Vit D Vit K Folate Iron Calcium

bull LAGB Folic Acid deficiency

bull BPD and BPDDS Vit A D E and K deficiency Protein-Calorie Malnutrition Malabsorption of

Calcium Zinc Selenium Sodium Potassium Chloride Phosphorus Magnesium

Recommended Daily Supplements(4)

Multivitamin with iron (prenatal vitamin will have adeq amount of folic acid)

Calcium (citrate) with vitamin D (1200-1500 mg calcium with 800-1000 IU vitamin D)

Oral vitamin B12 (500-1000 mcg) Iron (65 mgday in elemental form)

Vitamin C (to increase absorption of Iron) Thiamin (10 mgday)

Diet Recommendations(3)

Reduce food volume Chew food very well Slow pace of eating No liquids with meals Encourage fruits and vegetables as diet progresses Include high protein foods (at least 60gday) may need protein

supplements

Diet Progression Gastric Bypass

Stage 1 Clear liquids and protein supplement (1 week)

Stage 2No concentrated sweets low fat puree diet ( 3 weeks)

Stage 3 Regular texture weight reduction diet

Diet Progression Lap - Band

Stage 1 Clear liquids and protein supplement ( 2 weeks)

Stage 2 No concentrated sweets low fat puree diet (2weeks)

Stage 3 Regular texture weight reduction diet

Stage 1

Only clear liquids allowed Avoid sweetened beverages Sip very slowly No straws Avoid caffeinated carbonated and alcoholic beverages STOP drinking if you feel fullness pain or discomfort

Protein supplements

Begin the day after you go home from Hospital

Minimum protein target 70gmsday

May use powder or pre-mixed liquid forms (Whey protein is preferred)

Protein pills may not be used

Vitamin and Mineral Supplements

Gastric bypass patients In addition to eating much less food gastric bypass patients will also

absorb vitamins and minerals differently after surgery They will require daily multivitamin calcium and iron

supplementation for the rest of your life

Vitamin and Mineral Supplements

Lap-Bandreg patients

Require a multivitamin with minerals daily

It may be necessary to take additional vitamins and minerals eg calcium iron folateB1 B12These will be prescribed as needed

Stage 2 dietPUREE

Puree diet

Regular scheduled meals Avoid meal skipping Plan meals in advance Eat Slowly Eat protein foods first Moisten meats Use liquid protein as supplement not as meal replacement

Measure 2 oz portions at each meal eating when full Separate liquids and solids No bread rice or pasta Avoid added sugars and high fat

foods VARIETY

Dumping Syndrome

More than 15 patients Hypotention Tachycardia Lightheadedness syncope Flushing Abdominal cramping and diarrhea Nausea and vomiting

Dumping Syndrome

Occurs with high dose simple sugar ingestion Sugar in small intestine causes osmotic overload and fluid

shift from blood to intestine Increased intestinal volume leads to watery diarrhea Decreased blood volume leads to systemic changes Patient education

Eat slowly Avoid drinking before during and not until 30 minutes after meals

Constipation

Most common complaint Causes

Dehydration and decreased fluid intake post-operatively Increased metabolic water needs Calcium and iron supplement use following surgery

Treat with increased fluids and stool softeners

Nutritional Consequences

Iron deficiency anemia B12 deficiency Folate deficiency Calcium and Vitamin D deficiency

Not seen with purely restrictive surgeries

Iron deficiency and anemia

Common following RYGB As high as 49 of patients Multifactorial cause

Low gastric acid levels prohibit iron cleavage from food Absorption inhibited because no nutrient exposure to duodenum or

proximal jejunum Decrease in iron-rich food consumption due to intolerance

Treat with oral supplementation of ferrous sulfate or ferrous gluconate

Vitamin B12 deficiency

Up to 70 of patients Lack of hydrochloric acid and pepsin in stomach

Prevents B12 cleavage from food Affects secretion of intrinsic factor thus B12 absorption

Intolerance to meat and milk Oral supplementation usually adequate otherwise IM injections used

Folate Deficiency

40 of gastric bypass patients Complete absorption requires B12 Absorption dependent on HCl and upper 13 stomach Deficiency generally caused by decreased consumption Oral supplementation

Vitamin D and Calcium Deficiency

Vitamin D deficiency is common among obese people Calcium absorption decreased because duodenum is

bypassed Intolerance to dairy foods high in calcium Vitamin D is required for Ca++ absorption Prolonged deficiencies lead to

Bone resorption osteomalacia osteoporosis Treat with calcium citrate supplementation and 2 weekly

doses of Vitamin D

Nutritional Implications of Various Bariatric Surgeries(34)

bull RYGB Malabsorption of Vit B12 Vit B1 (thiamin) Vit D Vit K Folate Iron Calcium

bull LAGB Folic Acid deficiency

bull BPD and BPDDS Vit A D E and K deficiency Protein-Calorie Malnutrition Malabsorption of

Calcium Zinc Selenium Sodium Potassium Chloride Phosphorus Magnesium

Recommended Daily Supplements(4)

Multivitamin with iron (prenatal vitamin will have adeq amount of folic acid)

Calcium (citrate) with vitamin D (1200-1500 mg calcium with 800-1000 IU vitamin D)

Oral vitamin B12 (500-1000 mcg) Iron (65 mgday in elemental form)

Vitamin C (to increase absorption of Iron) Thiamin (10 mgday)

Diet Recommendations(3)

Reduce food volume Chew food very well Slow pace of eating No liquids with meals Encourage fruits and vegetables as diet progresses Include high protein foods (at least 60gday) may need protein

supplements

Diet Progression Gastric Bypass

Stage 1 Clear liquids and protein supplement (1 week)

Stage 2No concentrated sweets low fat puree diet ( 3 weeks)

Stage 3 Regular texture weight reduction diet

Diet Progression Lap - Band

Stage 1 Clear liquids and protein supplement ( 2 weeks)

Stage 2 No concentrated sweets low fat puree diet (2weeks)

Stage 3 Regular texture weight reduction diet

Stage 1

Only clear liquids allowed Avoid sweetened beverages Sip very slowly No straws Avoid caffeinated carbonated and alcoholic beverages STOP drinking if you feel fullness pain or discomfort

Protein supplements

Begin the day after you go home from Hospital

Minimum protein target 70gmsday

May use powder or pre-mixed liquid forms (Whey protein is preferred)

Protein pills may not be used

Vitamin and Mineral Supplements

Gastric bypass patients In addition to eating much less food gastric bypass patients will also

absorb vitamins and minerals differently after surgery They will require daily multivitamin calcium and iron

supplementation for the rest of your life

Vitamin and Mineral Supplements

Lap-Bandreg patients

Require a multivitamin with minerals daily

It may be necessary to take additional vitamins and minerals eg calcium iron folateB1 B12These will be prescribed as needed

Stage 2 dietPUREE

Puree diet

Regular scheduled meals Avoid meal skipping Plan meals in advance Eat Slowly Eat protein foods first Moisten meats Use liquid protein as supplement not as meal replacement

Measure 2 oz portions at each meal eating when full Separate liquids and solids No bread rice or pasta Avoid added sugars and high fat

foods VARIETY

Dumping Syndrome

Occurs with high dose simple sugar ingestion Sugar in small intestine causes osmotic overload and fluid

shift from blood to intestine Increased intestinal volume leads to watery diarrhea Decreased blood volume leads to systemic changes Patient education

Eat slowly Avoid drinking before during and not until 30 minutes after meals

Constipation

Most common complaint Causes

Dehydration and decreased fluid intake post-operatively Increased metabolic water needs Calcium and iron supplement use following surgery

Treat with increased fluids and stool softeners

Nutritional Consequences

Iron deficiency anemia B12 deficiency Folate deficiency Calcium and Vitamin D deficiency

Not seen with purely restrictive surgeries

Iron deficiency and anemia

Common following RYGB As high as 49 of patients Multifactorial cause

Low gastric acid levels prohibit iron cleavage from food Absorption inhibited because no nutrient exposure to duodenum or

proximal jejunum Decrease in iron-rich food consumption due to intolerance

Treat with oral supplementation of ferrous sulfate or ferrous gluconate

Vitamin B12 deficiency

Up to 70 of patients Lack of hydrochloric acid and pepsin in stomach

Prevents B12 cleavage from food Affects secretion of intrinsic factor thus B12 absorption

Intolerance to meat and milk Oral supplementation usually adequate otherwise IM injections used

Folate Deficiency

40 of gastric bypass patients Complete absorption requires B12 Absorption dependent on HCl and upper 13 stomach Deficiency generally caused by decreased consumption Oral supplementation

Vitamin D and Calcium Deficiency

Vitamin D deficiency is common among obese people Calcium absorption decreased because duodenum is

bypassed Intolerance to dairy foods high in calcium Vitamin D is required for Ca++ absorption Prolonged deficiencies lead to

Bone resorption osteomalacia osteoporosis Treat with calcium citrate supplementation and 2 weekly

doses of Vitamin D

Nutritional Implications of Various Bariatric Surgeries(34)

bull RYGB Malabsorption of Vit B12 Vit B1 (thiamin) Vit D Vit K Folate Iron Calcium

bull LAGB Folic Acid deficiency

bull BPD and BPDDS Vit A D E and K deficiency Protein-Calorie Malnutrition Malabsorption of

Calcium Zinc Selenium Sodium Potassium Chloride Phosphorus Magnesium

Recommended Daily Supplements(4)

Multivitamin with iron (prenatal vitamin will have adeq amount of folic acid)

Calcium (citrate) with vitamin D (1200-1500 mg calcium with 800-1000 IU vitamin D)

Oral vitamin B12 (500-1000 mcg) Iron (65 mgday in elemental form)

Vitamin C (to increase absorption of Iron) Thiamin (10 mgday)

Diet Recommendations(3)

Reduce food volume Chew food very well Slow pace of eating No liquids with meals Encourage fruits and vegetables as diet progresses Include high protein foods (at least 60gday) may need protein

supplements

Diet Progression Gastric Bypass

Stage 1 Clear liquids and protein supplement (1 week)

Stage 2No concentrated sweets low fat puree diet ( 3 weeks)

Stage 3 Regular texture weight reduction diet

Diet Progression Lap - Band

Stage 1 Clear liquids and protein supplement ( 2 weeks)

Stage 2 No concentrated sweets low fat puree diet (2weeks)

Stage 3 Regular texture weight reduction diet

Stage 1

Only clear liquids allowed Avoid sweetened beverages Sip very slowly No straws Avoid caffeinated carbonated and alcoholic beverages STOP drinking if you feel fullness pain or discomfort

Protein supplements

Begin the day after you go home from Hospital

Minimum protein target 70gmsday

May use powder or pre-mixed liquid forms (Whey protein is preferred)

Protein pills may not be used

Vitamin and Mineral Supplements

Gastric bypass patients In addition to eating much less food gastric bypass patients will also

absorb vitamins and minerals differently after surgery They will require daily multivitamin calcium and iron

supplementation for the rest of your life

Vitamin and Mineral Supplements

Lap-Bandreg patients

Require a multivitamin with minerals daily

It may be necessary to take additional vitamins and minerals eg calcium iron folateB1 B12These will be prescribed as needed

Stage 2 dietPUREE

Puree diet

Regular scheduled meals Avoid meal skipping Plan meals in advance Eat Slowly Eat protein foods first Moisten meats Use liquid protein as supplement not as meal replacement

Measure 2 oz portions at each meal eating when full Separate liquids and solids No bread rice or pasta Avoid added sugars and high fat

foods VARIETY

Constipation

Most common complaint Causes

Dehydration and decreased fluid intake post-operatively Increased metabolic water needs Calcium and iron supplement use following surgery

Treat with increased fluids and stool softeners

Nutritional Consequences

Iron deficiency anemia B12 deficiency Folate deficiency Calcium and Vitamin D deficiency

Not seen with purely restrictive surgeries

Iron deficiency and anemia

Common following RYGB As high as 49 of patients Multifactorial cause

Low gastric acid levels prohibit iron cleavage from food Absorption inhibited because no nutrient exposure to duodenum or

proximal jejunum Decrease in iron-rich food consumption due to intolerance

Treat with oral supplementation of ferrous sulfate or ferrous gluconate

Vitamin B12 deficiency

Up to 70 of patients Lack of hydrochloric acid and pepsin in stomach

Prevents B12 cleavage from food Affects secretion of intrinsic factor thus B12 absorption

Intolerance to meat and milk Oral supplementation usually adequate otherwise IM injections used

Folate Deficiency

40 of gastric bypass patients Complete absorption requires B12 Absorption dependent on HCl and upper 13 stomach Deficiency generally caused by decreased consumption Oral supplementation

Vitamin D and Calcium Deficiency

Vitamin D deficiency is common among obese people Calcium absorption decreased because duodenum is

bypassed Intolerance to dairy foods high in calcium Vitamin D is required for Ca++ absorption Prolonged deficiencies lead to

Bone resorption osteomalacia osteoporosis Treat with calcium citrate supplementation and 2 weekly

doses of Vitamin D

Nutritional Implications of Various Bariatric Surgeries(34)

bull RYGB Malabsorption of Vit B12 Vit B1 (thiamin) Vit D Vit K Folate Iron Calcium

bull LAGB Folic Acid deficiency

bull BPD and BPDDS Vit A D E and K deficiency Protein-Calorie Malnutrition Malabsorption of

Calcium Zinc Selenium Sodium Potassium Chloride Phosphorus Magnesium

Recommended Daily Supplements(4)

Multivitamin with iron (prenatal vitamin will have adeq amount of folic acid)

Calcium (citrate) with vitamin D (1200-1500 mg calcium with 800-1000 IU vitamin D)

Oral vitamin B12 (500-1000 mcg) Iron (65 mgday in elemental form)

Vitamin C (to increase absorption of Iron) Thiamin (10 mgday)

Diet Recommendations(3)

Reduce food volume Chew food very well Slow pace of eating No liquids with meals Encourage fruits and vegetables as diet progresses Include high protein foods (at least 60gday) may need protein

supplements

Diet Progression Gastric Bypass

Stage 1 Clear liquids and protein supplement (1 week)

Stage 2No concentrated sweets low fat puree diet ( 3 weeks)

Stage 3 Regular texture weight reduction diet

Diet Progression Lap - Band

Stage 1 Clear liquids and protein supplement ( 2 weeks)

Stage 2 No concentrated sweets low fat puree diet (2weeks)

Stage 3 Regular texture weight reduction diet

Stage 1

Only clear liquids allowed Avoid sweetened beverages Sip very slowly No straws Avoid caffeinated carbonated and alcoholic beverages STOP drinking if you feel fullness pain or discomfort

Protein supplements

Begin the day after you go home from Hospital

Minimum protein target 70gmsday

May use powder or pre-mixed liquid forms (Whey protein is preferred)

Protein pills may not be used

Vitamin and Mineral Supplements

Gastric bypass patients In addition to eating much less food gastric bypass patients will also

absorb vitamins and minerals differently after surgery They will require daily multivitamin calcium and iron

supplementation for the rest of your life

Vitamin and Mineral Supplements

Lap-Bandreg patients

Require a multivitamin with minerals daily

It may be necessary to take additional vitamins and minerals eg calcium iron folateB1 B12These will be prescribed as needed

Stage 2 dietPUREE

Puree diet

Regular scheduled meals Avoid meal skipping Plan meals in advance Eat Slowly Eat protein foods first Moisten meats Use liquid protein as supplement not as meal replacement

Measure 2 oz portions at each meal eating when full Separate liquids and solids No bread rice or pasta Avoid added sugars and high fat

foods VARIETY

Nutritional Consequences

Iron deficiency anemia B12 deficiency Folate deficiency Calcium and Vitamin D deficiency

Not seen with purely restrictive surgeries

Iron deficiency and anemia

Common following RYGB As high as 49 of patients Multifactorial cause

Low gastric acid levels prohibit iron cleavage from food Absorption inhibited because no nutrient exposure to duodenum or

proximal jejunum Decrease in iron-rich food consumption due to intolerance

Treat with oral supplementation of ferrous sulfate or ferrous gluconate

Vitamin B12 deficiency

Up to 70 of patients Lack of hydrochloric acid and pepsin in stomach

Prevents B12 cleavage from food Affects secretion of intrinsic factor thus B12 absorption

Intolerance to meat and milk Oral supplementation usually adequate otherwise IM injections used

Folate Deficiency

40 of gastric bypass patients Complete absorption requires B12 Absorption dependent on HCl and upper 13 stomach Deficiency generally caused by decreased consumption Oral supplementation

Vitamin D and Calcium Deficiency

Vitamin D deficiency is common among obese people Calcium absorption decreased because duodenum is

bypassed Intolerance to dairy foods high in calcium Vitamin D is required for Ca++ absorption Prolonged deficiencies lead to

Bone resorption osteomalacia osteoporosis Treat with calcium citrate supplementation and 2 weekly

doses of Vitamin D

Nutritional Implications of Various Bariatric Surgeries(34)

bull RYGB Malabsorption of Vit B12 Vit B1 (thiamin) Vit D Vit K Folate Iron Calcium

bull LAGB Folic Acid deficiency

bull BPD and BPDDS Vit A D E and K deficiency Protein-Calorie Malnutrition Malabsorption of

Calcium Zinc Selenium Sodium Potassium Chloride Phosphorus Magnesium

Recommended Daily Supplements(4)

Multivitamin with iron (prenatal vitamin will have adeq amount of folic acid)

Calcium (citrate) with vitamin D (1200-1500 mg calcium with 800-1000 IU vitamin D)

Oral vitamin B12 (500-1000 mcg) Iron (65 mgday in elemental form)

Vitamin C (to increase absorption of Iron) Thiamin (10 mgday)

Diet Recommendations(3)

Reduce food volume Chew food very well Slow pace of eating No liquids with meals Encourage fruits and vegetables as diet progresses Include high protein foods (at least 60gday) may need protein

supplements

Diet Progression Gastric Bypass

Stage 1 Clear liquids and protein supplement (1 week)

Stage 2No concentrated sweets low fat puree diet ( 3 weeks)

Stage 3 Regular texture weight reduction diet

Diet Progression Lap - Band

Stage 1 Clear liquids and protein supplement ( 2 weeks)

Stage 2 No concentrated sweets low fat puree diet (2weeks)

Stage 3 Regular texture weight reduction diet

Stage 1

Only clear liquids allowed Avoid sweetened beverages Sip very slowly No straws Avoid caffeinated carbonated and alcoholic beverages STOP drinking if you feel fullness pain or discomfort

Protein supplements

Begin the day after you go home from Hospital

Minimum protein target 70gmsday

May use powder or pre-mixed liquid forms (Whey protein is preferred)

Protein pills may not be used

Vitamin and Mineral Supplements

Gastric bypass patients In addition to eating much less food gastric bypass patients will also

absorb vitamins and minerals differently after surgery They will require daily multivitamin calcium and iron

supplementation for the rest of your life

Vitamin and Mineral Supplements

Lap-Bandreg patients

Require a multivitamin with minerals daily

It may be necessary to take additional vitamins and minerals eg calcium iron folateB1 B12These will be prescribed as needed

Stage 2 dietPUREE

Puree diet

Regular scheduled meals Avoid meal skipping Plan meals in advance Eat Slowly Eat protein foods first Moisten meats Use liquid protein as supplement not as meal replacement

Measure 2 oz portions at each meal eating when full Separate liquids and solids No bread rice or pasta Avoid added sugars and high fat

foods VARIETY

Iron deficiency and anemia

Common following RYGB As high as 49 of patients Multifactorial cause

Low gastric acid levels prohibit iron cleavage from food Absorption inhibited because no nutrient exposure to duodenum or

proximal jejunum Decrease in iron-rich food consumption due to intolerance

Treat with oral supplementation of ferrous sulfate or ferrous gluconate

Vitamin B12 deficiency

Up to 70 of patients Lack of hydrochloric acid and pepsin in stomach

Prevents B12 cleavage from food Affects secretion of intrinsic factor thus B12 absorption

Intolerance to meat and milk Oral supplementation usually adequate otherwise IM injections used

Folate Deficiency

40 of gastric bypass patients Complete absorption requires B12 Absorption dependent on HCl and upper 13 stomach Deficiency generally caused by decreased consumption Oral supplementation

Vitamin D and Calcium Deficiency

Vitamin D deficiency is common among obese people Calcium absorption decreased because duodenum is

bypassed Intolerance to dairy foods high in calcium Vitamin D is required for Ca++ absorption Prolonged deficiencies lead to

Bone resorption osteomalacia osteoporosis Treat with calcium citrate supplementation and 2 weekly

doses of Vitamin D

Nutritional Implications of Various Bariatric Surgeries(34)

bull RYGB Malabsorption of Vit B12 Vit B1 (thiamin) Vit D Vit K Folate Iron Calcium

bull LAGB Folic Acid deficiency

bull BPD and BPDDS Vit A D E and K deficiency Protein-Calorie Malnutrition Malabsorption of

Calcium Zinc Selenium Sodium Potassium Chloride Phosphorus Magnesium

Recommended Daily Supplements(4)

Multivitamin with iron (prenatal vitamin will have adeq amount of folic acid)

Calcium (citrate) with vitamin D (1200-1500 mg calcium with 800-1000 IU vitamin D)

Oral vitamin B12 (500-1000 mcg) Iron (65 mgday in elemental form)

Vitamin C (to increase absorption of Iron) Thiamin (10 mgday)

Diet Recommendations(3)

Reduce food volume Chew food very well Slow pace of eating No liquids with meals Encourage fruits and vegetables as diet progresses Include high protein foods (at least 60gday) may need protein

supplements

Diet Progression Gastric Bypass

Stage 1 Clear liquids and protein supplement (1 week)

Stage 2No concentrated sweets low fat puree diet ( 3 weeks)

Stage 3 Regular texture weight reduction diet

Diet Progression Lap - Band

Stage 1 Clear liquids and protein supplement ( 2 weeks)

Stage 2 No concentrated sweets low fat puree diet (2weeks)

Stage 3 Regular texture weight reduction diet

Stage 1

Only clear liquids allowed Avoid sweetened beverages Sip very slowly No straws Avoid caffeinated carbonated and alcoholic beverages STOP drinking if you feel fullness pain or discomfort

Protein supplements

Begin the day after you go home from Hospital

Minimum protein target 70gmsday

May use powder or pre-mixed liquid forms (Whey protein is preferred)

Protein pills may not be used

Vitamin and Mineral Supplements

Gastric bypass patients In addition to eating much less food gastric bypass patients will also

absorb vitamins and minerals differently after surgery They will require daily multivitamin calcium and iron

supplementation for the rest of your life

Vitamin and Mineral Supplements

Lap-Bandreg patients

Require a multivitamin with minerals daily

It may be necessary to take additional vitamins and minerals eg calcium iron folateB1 B12These will be prescribed as needed

Stage 2 dietPUREE

Puree diet

Regular scheduled meals Avoid meal skipping Plan meals in advance Eat Slowly Eat protein foods first Moisten meats Use liquid protein as supplement not as meal replacement

Measure 2 oz portions at each meal eating when full Separate liquids and solids No bread rice or pasta Avoid added sugars and high fat

foods VARIETY

Vitamin B12 deficiency

Up to 70 of patients Lack of hydrochloric acid and pepsin in stomach

Prevents B12 cleavage from food Affects secretion of intrinsic factor thus B12 absorption

Intolerance to meat and milk Oral supplementation usually adequate otherwise IM injections used

Folate Deficiency

40 of gastric bypass patients Complete absorption requires B12 Absorption dependent on HCl and upper 13 stomach Deficiency generally caused by decreased consumption Oral supplementation

Vitamin D and Calcium Deficiency

Vitamin D deficiency is common among obese people Calcium absorption decreased because duodenum is

bypassed Intolerance to dairy foods high in calcium Vitamin D is required for Ca++ absorption Prolonged deficiencies lead to

Bone resorption osteomalacia osteoporosis Treat with calcium citrate supplementation and 2 weekly

doses of Vitamin D

Nutritional Implications of Various Bariatric Surgeries(34)

bull RYGB Malabsorption of Vit B12 Vit B1 (thiamin) Vit D Vit K Folate Iron Calcium

bull LAGB Folic Acid deficiency

bull BPD and BPDDS Vit A D E and K deficiency Protein-Calorie Malnutrition Malabsorption of

Calcium Zinc Selenium Sodium Potassium Chloride Phosphorus Magnesium

Recommended Daily Supplements(4)

Multivitamin with iron (prenatal vitamin will have adeq amount of folic acid)

Calcium (citrate) with vitamin D (1200-1500 mg calcium with 800-1000 IU vitamin D)

Oral vitamin B12 (500-1000 mcg) Iron (65 mgday in elemental form)

Vitamin C (to increase absorption of Iron) Thiamin (10 mgday)

Diet Recommendations(3)

Reduce food volume Chew food very well Slow pace of eating No liquids with meals Encourage fruits and vegetables as diet progresses Include high protein foods (at least 60gday) may need protein

supplements

Diet Progression Gastric Bypass

Stage 1 Clear liquids and protein supplement (1 week)

Stage 2No concentrated sweets low fat puree diet ( 3 weeks)

Stage 3 Regular texture weight reduction diet

Diet Progression Lap - Band

Stage 1 Clear liquids and protein supplement ( 2 weeks)

Stage 2 No concentrated sweets low fat puree diet (2weeks)

Stage 3 Regular texture weight reduction diet

Stage 1

Only clear liquids allowed Avoid sweetened beverages Sip very slowly No straws Avoid caffeinated carbonated and alcoholic beverages STOP drinking if you feel fullness pain or discomfort

Protein supplements

Begin the day after you go home from Hospital

Minimum protein target 70gmsday

May use powder or pre-mixed liquid forms (Whey protein is preferred)

Protein pills may not be used

Vitamin and Mineral Supplements

Gastric bypass patients In addition to eating much less food gastric bypass patients will also

absorb vitamins and minerals differently after surgery They will require daily multivitamin calcium and iron

supplementation for the rest of your life

Vitamin and Mineral Supplements

Lap-Bandreg patients

Require a multivitamin with minerals daily

It may be necessary to take additional vitamins and minerals eg calcium iron folateB1 B12These will be prescribed as needed

Stage 2 dietPUREE

Puree diet

Regular scheduled meals Avoid meal skipping Plan meals in advance Eat Slowly Eat protein foods first Moisten meats Use liquid protein as supplement not as meal replacement

Measure 2 oz portions at each meal eating when full Separate liquids and solids No bread rice or pasta Avoid added sugars and high fat

foods VARIETY

Folate Deficiency

40 of gastric bypass patients Complete absorption requires B12 Absorption dependent on HCl and upper 13 stomach Deficiency generally caused by decreased consumption Oral supplementation

Vitamin D and Calcium Deficiency

Vitamin D deficiency is common among obese people Calcium absorption decreased because duodenum is

bypassed Intolerance to dairy foods high in calcium Vitamin D is required for Ca++ absorption Prolonged deficiencies lead to

Bone resorption osteomalacia osteoporosis Treat with calcium citrate supplementation and 2 weekly

doses of Vitamin D

Nutritional Implications of Various Bariatric Surgeries(34)

bull RYGB Malabsorption of Vit B12 Vit B1 (thiamin) Vit D Vit K Folate Iron Calcium

bull LAGB Folic Acid deficiency

bull BPD and BPDDS Vit A D E and K deficiency Protein-Calorie Malnutrition Malabsorption of

Calcium Zinc Selenium Sodium Potassium Chloride Phosphorus Magnesium

Recommended Daily Supplements(4)

Multivitamin with iron (prenatal vitamin will have adeq amount of folic acid)

Calcium (citrate) with vitamin D (1200-1500 mg calcium with 800-1000 IU vitamin D)

Oral vitamin B12 (500-1000 mcg) Iron (65 mgday in elemental form)

Vitamin C (to increase absorption of Iron) Thiamin (10 mgday)

Diet Recommendations(3)

Reduce food volume Chew food very well Slow pace of eating No liquids with meals Encourage fruits and vegetables as diet progresses Include high protein foods (at least 60gday) may need protein

supplements

Diet Progression Gastric Bypass

Stage 1 Clear liquids and protein supplement (1 week)

Stage 2No concentrated sweets low fat puree diet ( 3 weeks)

Stage 3 Regular texture weight reduction diet

Diet Progression Lap - Band

Stage 1 Clear liquids and protein supplement ( 2 weeks)

Stage 2 No concentrated sweets low fat puree diet (2weeks)

Stage 3 Regular texture weight reduction diet

Stage 1

Only clear liquids allowed Avoid sweetened beverages Sip very slowly No straws Avoid caffeinated carbonated and alcoholic beverages STOP drinking if you feel fullness pain or discomfort

Protein supplements

Begin the day after you go home from Hospital

Minimum protein target 70gmsday

May use powder or pre-mixed liquid forms (Whey protein is preferred)

Protein pills may not be used

Vitamin and Mineral Supplements

Gastric bypass patients In addition to eating much less food gastric bypass patients will also

absorb vitamins and minerals differently after surgery They will require daily multivitamin calcium and iron

supplementation for the rest of your life

Vitamin and Mineral Supplements

Lap-Bandreg patients

Require a multivitamin with minerals daily

It may be necessary to take additional vitamins and minerals eg calcium iron folateB1 B12These will be prescribed as needed

Stage 2 dietPUREE

Puree diet

Regular scheduled meals Avoid meal skipping Plan meals in advance Eat Slowly Eat protein foods first Moisten meats Use liquid protein as supplement not as meal replacement

Measure 2 oz portions at each meal eating when full Separate liquids and solids No bread rice or pasta Avoid added sugars and high fat

foods VARIETY

Vitamin D and Calcium Deficiency

Vitamin D deficiency is common among obese people Calcium absorption decreased because duodenum is

bypassed Intolerance to dairy foods high in calcium Vitamin D is required for Ca++ absorption Prolonged deficiencies lead to

Bone resorption osteomalacia osteoporosis Treat with calcium citrate supplementation and 2 weekly

doses of Vitamin D

Nutritional Implications of Various Bariatric Surgeries(34)

bull RYGB Malabsorption of Vit B12 Vit B1 (thiamin) Vit D Vit K Folate Iron Calcium

bull LAGB Folic Acid deficiency

bull BPD and BPDDS Vit A D E and K deficiency Protein-Calorie Malnutrition Malabsorption of

Calcium Zinc Selenium Sodium Potassium Chloride Phosphorus Magnesium

Recommended Daily Supplements(4)

Multivitamin with iron (prenatal vitamin will have adeq amount of folic acid)

Calcium (citrate) with vitamin D (1200-1500 mg calcium with 800-1000 IU vitamin D)

Oral vitamin B12 (500-1000 mcg) Iron (65 mgday in elemental form)

Vitamin C (to increase absorption of Iron) Thiamin (10 mgday)

Diet Recommendations(3)

Reduce food volume Chew food very well Slow pace of eating No liquids with meals Encourage fruits and vegetables as diet progresses Include high protein foods (at least 60gday) may need protein

supplements

Diet Progression Gastric Bypass

Stage 1 Clear liquids and protein supplement (1 week)

Stage 2No concentrated sweets low fat puree diet ( 3 weeks)

Stage 3 Regular texture weight reduction diet

Diet Progression Lap - Band

Stage 1 Clear liquids and protein supplement ( 2 weeks)

Stage 2 No concentrated sweets low fat puree diet (2weeks)

Stage 3 Regular texture weight reduction diet

Stage 1

Only clear liquids allowed Avoid sweetened beverages Sip very slowly No straws Avoid caffeinated carbonated and alcoholic beverages STOP drinking if you feel fullness pain or discomfort

Protein supplements

Begin the day after you go home from Hospital

Minimum protein target 70gmsday

May use powder or pre-mixed liquid forms (Whey protein is preferred)

Protein pills may not be used

Vitamin and Mineral Supplements

Gastric bypass patients In addition to eating much less food gastric bypass patients will also

absorb vitamins and minerals differently after surgery They will require daily multivitamin calcium and iron

supplementation for the rest of your life

Vitamin and Mineral Supplements

Lap-Bandreg patients

Require a multivitamin with minerals daily

It may be necessary to take additional vitamins and minerals eg calcium iron folateB1 B12These will be prescribed as needed

Stage 2 dietPUREE

Puree diet

Regular scheduled meals Avoid meal skipping Plan meals in advance Eat Slowly Eat protein foods first Moisten meats Use liquid protein as supplement not as meal replacement

Measure 2 oz portions at each meal eating when full Separate liquids and solids No bread rice or pasta Avoid added sugars and high fat

foods VARIETY

Nutritional Implications of Various Bariatric Surgeries(34)

bull RYGB Malabsorption of Vit B12 Vit B1 (thiamin) Vit D Vit K Folate Iron Calcium

bull LAGB Folic Acid deficiency

bull BPD and BPDDS Vit A D E and K deficiency Protein-Calorie Malnutrition Malabsorption of

Calcium Zinc Selenium Sodium Potassium Chloride Phosphorus Magnesium

Recommended Daily Supplements(4)

Multivitamin with iron (prenatal vitamin will have adeq amount of folic acid)

Calcium (citrate) with vitamin D (1200-1500 mg calcium with 800-1000 IU vitamin D)

Oral vitamin B12 (500-1000 mcg) Iron (65 mgday in elemental form)

Vitamin C (to increase absorption of Iron) Thiamin (10 mgday)

Diet Recommendations(3)

Reduce food volume Chew food very well Slow pace of eating No liquids with meals Encourage fruits and vegetables as diet progresses Include high protein foods (at least 60gday) may need protein

supplements

Diet Progression Gastric Bypass

Stage 1 Clear liquids and protein supplement (1 week)

Stage 2No concentrated sweets low fat puree diet ( 3 weeks)

Stage 3 Regular texture weight reduction diet

Diet Progression Lap - Band

Stage 1 Clear liquids and protein supplement ( 2 weeks)

Stage 2 No concentrated sweets low fat puree diet (2weeks)

Stage 3 Regular texture weight reduction diet

Stage 1

Only clear liquids allowed Avoid sweetened beverages Sip very slowly No straws Avoid caffeinated carbonated and alcoholic beverages STOP drinking if you feel fullness pain or discomfort

Protein supplements

Begin the day after you go home from Hospital

Minimum protein target 70gmsday

May use powder or pre-mixed liquid forms (Whey protein is preferred)

Protein pills may not be used

Vitamin and Mineral Supplements

Gastric bypass patients In addition to eating much less food gastric bypass patients will also

absorb vitamins and minerals differently after surgery They will require daily multivitamin calcium and iron

supplementation for the rest of your life

Vitamin and Mineral Supplements

Lap-Bandreg patients

Require a multivitamin with minerals daily

It may be necessary to take additional vitamins and minerals eg calcium iron folateB1 B12These will be prescribed as needed

Stage 2 dietPUREE

Puree diet

Regular scheduled meals Avoid meal skipping Plan meals in advance Eat Slowly Eat protein foods first Moisten meats Use liquid protein as supplement not as meal replacement

Measure 2 oz portions at each meal eating when full Separate liquids and solids No bread rice or pasta Avoid added sugars and high fat

foods VARIETY

Recommended Daily Supplements(4)

Multivitamin with iron (prenatal vitamin will have adeq amount of folic acid)

Calcium (citrate) with vitamin D (1200-1500 mg calcium with 800-1000 IU vitamin D)

Oral vitamin B12 (500-1000 mcg) Iron (65 mgday in elemental form)

Vitamin C (to increase absorption of Iron) Thiamin (10 mgday)

Diet Recommendations(3)

Reduce food volume Chew food very well Slow pace of eating No liquids with meals Encourage fruits and vegetables as diet progresses Include high protein foods (at least 60gday) may need protein

supplements

Diet Progression Gastric Bypass

Stage 1 Clear liquids and protein supplement (1 week)

Stage 2No concentrated sweets low fat puree diet ( 3 weeks)

Stage 3 Regular texture weight reduction diet

Diet Progression Lap - Band

Stage 1 Clear liquids and protein supplement ( 2 weeks)

Stage 2 No concentrated sweets low fat puree diet (2weeks)

Stage 3 Regular texture weight reduction diet

Stage 1

Only clear liquids allowed Avoid sweetened beverages Sip very slowly No straws Avoid caffeinated carbonated and alcoholic beverages STOP drinking if you feel fullness pain or discomfort

Protein supplements

Begin the day after you go home from Hospital

Minimum protein target 70gmsday

May use powder or pre-mixed liquid forms (Whey protein is preferred)

Protein pills may not be used

Vitamin and Mineral Supplements

Gastric bypass patients In addition to eating much less food gastric bypass patients will also

absorb vitamins and minerals differently after surgery They will require daily multivitamin calcium and iron

supplementation for the rest of your life

Vitamin and Mineral Supplements

Lap-Bandreg patients

Require a multivitamin with minerals daily

It may be necessary to take additional vitamins and minerals eg calcium iron folateB1 B12These will be prescribed as needed

Stage 2 dietPUREE

Puree diet

Regular scheduled meals Avoid meal skipping Plan meals in advance Eat Slowly Eat protein foods first Moisten meats Use liquid protein as supplement not as meal replacement

Measure 2 oz portions at each meal eating when full Separate liquids and solids No bread rice or pasta Avoid added sugars and high fat

foods VARIETY

Diet Recommendations(3)

Reduce food volume Chew food very well Slow pace of eating No liquids with meals Encourage fruits and vegetables as diet progresses Include high protein foods (at least 60gday) may need protein

supplements

Diet Progression Gastric Bypass

Stage 1 Clear liquids and protein supplement (1 week)

Stage 2No concentrated sweets low fat puree diet ( 3 weeks)

Stage 3 Regular texture weight reduction diet

Diet Progression Lap - Band

Stage 1 Clear liquids and protein supplement ( 2 weeks)

Stage 2 No concentrated sweets low fat puree diet (2weeks)

Stage 3 Regular texture weight reduction diet

Stage 1

Only clear liquids allowed Avoid sweetened beverages Sip very slowly No straws Avoid caffeinated carbonated and alcoholic beverages STOP drinking if you feel fullness pain or discomfort

Protein supplements

Begin the day after you go home from Hospital

Minimum protein target 70gmsday

May use powder or pre-mixed liquid forms (Whey protein is preferred)

Protein pills may not be used

Vitamin and Mineral Supplements

Gastric bypass patients In addition to eating much less food gastric bypass patients will also

absorb vitamins and minerals differently after surgery They will require daily multivitamin calcium and iron

supplementation for the rest of your life

Vitamin and Mineral Supplements

Lap-Bandreg patients

Require a multivitamin with minerals daily

It may be necessary to take additional vitamins and minerals eg calcium iron folateB1 B12These will be prescribed as needed

Stage 2 dietPUREE

Puree diet

Regular scheduled meals Avoid meal skipping Plan meals in advance Eat Slowly Eat protein foods first Moisten meats Use liquid protein as supplement not as meal replacement

Measure 2 oz portions at each meal eating when full Separate liquids and solids No bread rice or pasta Avoid added sugars and high fat

foods VARIETY

Diet Progression Gastric Bypass

Stage 1 Clear liquids and protein supplement (1 week)

Stage 2No concentrated sweets low fat puree diet ( 3 weeks)

Stage 3 Regular texture weight reduction diet

Diet Progression Lap - Band

Stage 1 Clear liquids and protein supplement ( 2 weeks)

Stage 2 No concentrated sweets low fat puree diet (2weeks)

Stage 3 Regular texture weight reduction diet

Stage 1

Only clear liquids allowed Avoid sweetened beverages Sip very slowly No straws Avoid caffeinated carbonated and alcoholic beverages STOP drinking if you feel fullness pain or discomfort

Protein supplements

Begin the day after you go home from Hospital

Minimum protein target 70gmsday

May use powder or pre-mixed liquid forms (Whey protein is preferred)

Protein pills may not be used

Vitamin and Mineral Supplements

Gastric bypass patients In addition to eating much less food gastric bypass patients will also

absorb vitamins and minerals differently after surgery They will require daily multivitamin calcium and iron

supplementation for the rest of your life

Vitamin and Mineral Supplements

Lap-Bandreg patients

Require a multivitamin with minerals daily

It may be necessary to take additional vitamins and minerals eg calcium iron folateB1 B12These will be prescribed as needed

Stage 2 dietPUREE

Puree diet

Regular scheduled meals Avoid meal skipping Plan meals in advance Eat Slowly Eat protein foods first Moisten meats Use liquid protein as supplement not as meal replacement

Measure 2 oz portions at each meal eating when full Separate liquids and solids No bread rice or pasta Avoid added sugars and high fat

foods VARIETY

Diet Progression Lap - Band

Stage 1 Clear liquids and protein supplement ( 2 weeks)

Stage 2 No concentrated sweets low fat puree diet (2weeks)

Stage 3 Regular texture weight reduction diet

Stage 1

Only clear liquids allowed Avoid sweetened beverages Sip very slowly No straws Avoid caffeinated carbonated and alcoholic beverages STOP drinking if you feel fullness pain or discomfort

Protein supplements

Begin the day after you go home from Hospital

Minimum protein target 70gmsday

May use powder or pre-mixed liquid forms (Whey protein is preferred)

Protein pills may not be used

Vitamin and Mineral Supplements

Gastric bypass patients In addition to eating much less food gastric bypass patients will also

absorb vitamins and minerals differently after surgery They will require daily multivitamin calcium and iron

supplementation for the rest of your life

Vitamin and Mineral Supplements

Lap-Bandreg patients

Require a multivitamin with minerals daily

It may be necessary to take additional vitamins and minerals eg calcium iron folateB1 B12These will be prescribed as needed

Stage 2 dietPUREE

Puree diet

Regular scheduled meals Avoid meal skipping Plan meals in advance Eat Slowly Eat protein foods first Moisten meats Use liquid protein as supplement not as meal replacement

Measure 2 oz portions at each meal eating when full Separate liquids and solids No bread rice or pasta Avoid added sugars and high fat

foods VARIETY

Stage 1

Only clear liquids allowed Avoid sweetened beverages Sip very slowly No straws Avoid caffeinated carbonated and alcoholic beverages STOP drinking if you feel fullness pain or discomfort

Protein supplements

Begin the day after you go home from Hospital

Minimum protein target 70gmsday

May use powder or pre-mixed liquid forms (Whey protein is preferred)

Protein pills may not be used

Vitamin and Mineral Supplements

Gastric bypass patients In addition to eating much less food gastric bypass patients will also

absorb vitamins and minerals differently after surgery They will require daily multivitamin calcium and iron

supplementation for the rest of your life

Vitamin and Mineral Supplements

Lap-Bandreg patients

Require a multivitamin with minerals daily

It may be necessary to take additional vitamins and minerals eg calcium iron folateB1 B12These will be prescribed as needed

Stage 2 dietPUREE

Puree diet

Regular scheduled meals Avoid meal skipping Plan meals in advance Eat Slowly Eat protein foods first Moisten meats Use liquid protein as supplement not as meal replacement

Measure 2 oz portions at each meal eating when full Separate liquids and solids No bread rice or pasta Avoid added sugars and high fat

foods VARIETY

Protein supplements

Begin the day after you go home from Hospital

Minimum protein target 70gmsday

May use powder or pre-mixed liquid forms (Whey protein is preferred)

Protein pills may not be used

Vitamin and Mineral Supplements

Gastric bypass patients In addition to eating much less food gastric bypass patients will also

absorb vitamins and minerals differently after surgery They will require daily multivitamin calcium and iron

supplementation for the rest of your life

Vitamin and Mineral Supplements

Lap-Bandreg patients

Require a multivitamin with minerals daily

It may be necessary to take additional vitamins and minerals eg calcium iron folateB1 B12These will be prescribed as needed

Stage 2 dietPUREE

Puree diet

Regular scheduled meals Avoid meal skipping Plan meals in advance Eat Slowly Eat protein foods first Moisten meats Use liquid protein as supplement not as meal replacement

Measure 2 oz portions at each meal eating when full Separate liquids and solids No bread rice or pasta Avoid added sugars and high fat

foods VARIETY

Vitamin and Mineral Supplements

Gastric bypass patients In addition to eating much less food gastric bypass patients will also

absorb vitamins and minerals differently after surgery They will require daily multivitamin calcium and iron

supplementation for the rest of your life

Vitamin and Mineral Supplements

Lap-Bandreg patients

Require a multivitamin with minerals daily

It may be necessary to take additional vitamins and minerals eg calcium iron folateB1 B12These will be prescribed as needed

Stage 2 dietPUREE

Puree diet

Regular scheduled meals Avoid meal skipping Plan meals in advance Eat Slowly Eat protein foods first Moisten meats Use liquid protein as supplement not as meal replacement

Measure 2 oz portions at each meal eating when full Separate liquids and solids No bread rice or pasta Avoid added sugars and high fat

foods VARIETY

Vitamin and Mineral Supplements

Lap-Bandreg patients

Require a multivitamin with minerals daily

It may be necessary to take additional vitamins and minerals eg calcium iron folateB1 B12These will be prescribed as needed

Stage 2 dietPUREE

Puree diet

Regular scheduled meals Avoid meal skipping Plan meals in advance Eat Slowly Eat protein foods first Moisten meats Use liquid protein as supplement not as meal replacement

Measure 2 oz portions at each meal eating when full Separate liquids and solids No bread rice or pasta Avoid added sugars and high fat

foods VARIETY

Stage 2 dietPUREE

Puree diet

Regular scheduled meals Avoid meal skipping Plan meals in advance Eat Slowly Eat protein foods first Moisten meats Use liquid protein as supplement not as meal replacement

Measure 2 oz portions at each meal eating when full Separate liquids and solids No bread rice or pasta Avoid added sugars and high fat

foods VARIETY

Puree diet

Regular scheduled meals Avoid meal skipping Plan meals in advance Eat Slowly Eat protein foods first Moisten meats Use liquid protein as supplement not as meal replacement

Measure 2 oz portions at each meal eating when full Separate liquids and solids No bread rice or pasta Avoid added sugars and high fat

foods VARIETY

Stage 3 diet NO CONCENTRATED SWEETS LOW FAT CALORIE CONTROLLED DIET

Stage 3 diet

Continue to eat blended food adding one new solid food at a time

Dice meats Chew slowly Food intolerances vary Prioritize protein rich foods Daily MVI calcium and iron Gradually increase meal size to 4-5 oz

Stage 3 continued

Avoid meal skippingContinue to separate liquids and solidsProtein intake assessed and supplement

will be adjustedeliminated accordingly

Common post-operative nutritional problems

Nausea Vomiting Dehydration Frothing Diarrhea Dumping Syndrome Dizziness Bad Breath Loss of appetite Food gettingrdquostuckrdquo

Hair Loss Lactose intolerance Vitaminmineral deficiencies Protein malnutrition Food intolerances Food aversionsfears Depression often caused by frustration around inability to eat for

comfortstress ldquoHibernation ldquo Syndrome

Late post ndashoperative complicationWeight Gain

Grazing Snacking on left ndashover meals Hidden calories Alcohol Poor food choices Carbonated beverages Lack of exercise Failure to check weight regularly Not attending follow up visits with Bariatric Surgeon

Post-Op Monitoring

Follow-up Lab Tests

Every 3 months for the first year

CBC glucose creatinine

Every 6 months for the first year

LFTs protein and albumin iron TIBC ferritin vitamin B12 folic acid calcium parathyroid hormone (if hypercalcemic)

Every year after the first year All of the above

Importance of Aftercare

Surgery is only the beginning Initially the ldquofull time jobrdquo is learning to eat Team approach to follow up you are an important player Primary goal is to maintain good nutrition ldquoKeep folks on the roadrdquo

Long-Term ComplicationsSide Effects ndash Skin Issues

Severe infection of the excess abdominal skin

Treat with antibiotics and skin hygiene

Consider excision of the excess skin

The most common areas subject to plastic surgery procedures are the abdomen thighs and buttocks

These areas are very susceptible to treatment with a combination of liposuction and body lifting procedures

When the face and the neck are involved the surgical corrections follow the same principle of liftingtightening the skin and subdermal tissues

Mastopexy or breast lift is also a very common procedure as patients almost universally complain of ptosis and atrophy of the mammary tissue

Stage 3 diet

Continue to eat blended food adding one new solid food at a time

Dice meats Chew slowly Food intolerances vary Prioritize protein rich foods Daily MVI calcium and iron Gradually increase meal size to 4-5 oz

Stage 3 continued

Avoid meal skippingContinue to separate liquids and solidsProtein intake assessed and supplement

will be adjustedeliminated accordingly

Common post-operative nutritional problems

Nausea Vomiting Dehydration Frothing Diarrhea Dumping Syndrome Dizziness Bad Breath Loss of appetite Food gettingrdquostuckrdquo

Hair Loss Lactose intolerance Vitaminmineral deficiencies Protein malnutrition Food intolerances Food aversionsfears Depression often caused by frustration around inability to eat for

comfortstress ldquoHibernation ldquo Syndrome

Late post ndashoperative complicationWeight Gain

Grazing Snacking on left ndashover meals Hidden calories Alcohol Poor food choices Carbonated beverages Lack of exercise Failure to check weight regularly Not attending follow up visits with Bariatric Surgeon

Post-Op Monitoring

Follow-up Lab Tests

Every 3 months for the first year

CBC glucose creatinine

Every 6 months for the first year

LFTs protein and albumin iron TIBC ferritin vitamin B12 folic acid calcium parathyroid hormone (if hypercalcemic)

Every year after the first year All of the above

Importance of Aftercare

Surgery is only the beginning Initially the ldquofull time jobrdquo is learning to eat Team approach to follow up you are an important player Primary goal is to maintain good nutrition ldquoKeep folks on the roadrdquo

Long-Term ComplicationsSide Effects ndash Skin Issues

Severe infection of the excess abdominal skin

Treat with antibiotics and skin hygiene

Consider excision of the excess skin

The most common areas subject to plastic surgery procedures are the abdomen thighs and buttocks

These areas are very susceptible to treatment with a combination of liposuction and body lifting procedures

When the face and the neck are involved the surgical corrections follow the same principle of liftingtightening the skin and subdermal tissues

Mastopexy or breast lift is also a very common procedure as patients almost universally complain of ptosis and atrophy of the mammary tissue

Stage 3 continued

Avoid meal skippingContinue to separate liquids and solidsProtein intake assessed and supplement

will be adjustedeliminated accordingly

Common post-operative nutritional problems

Nausea Vomiting Dehydration Frothing Diarrhea Dumping Syndrome Dizziness Bad Breath Loss of appetite Food gettingrdquostuckrdquo

Hair Loss Lactose intolerance Vitaminmineral deficiencies Protein malnutrition Food intolerances Food aversionsfears Depression often caused by frustration around inability to eat for

comfortstress ldquoHibernation ldquo Syndrome

Late post ndashoperative complicationWeight Gain

Grazing Snacking on left ndashover meals Hidden calories Alcohol Poor food choices Carbonated beverages Lack of exercise Failure to check weight regularly Not attending follow up visits with Bariatric Surgeon

Post-Op Monitoring

Follow-up Lab Tests

Every 3 months for the first year

CBC glucose creatinine

Every 6 months for the first year

LFTs protein and albumin iron TIBC ferritin vitamin B12 folic acid calcium parathyroid hormone (if hypercalcemic)

Every year after the first year All of the above

Importance of Aftercare

Surgery is only the beginning Initially the ldquofull time jobrdquo is learning to eat Team approach to follow up you are an important player Primary goal is to maintain good nutrition ldquoKeep folks on the roadrdquo

Long-Term ComplicationsSide Effects ndash Skin Issues

Severe infection of the excess abdominal skin

Treat with antibiotics and skin hygiene

Consider excision of the excess skin

The most common areas subject to plastic surgery procedures are the abdomen thighs and buttocks

These areas are very susceptible to treatment with a combination of liposuction and body lifting procedures

When the face and the neck are involved the surgical corrections follow the same principle of liftingtightening the skin and subdermal tissues

Mastopexy or breast lift is also a very common procedure as patients almost universally complain of ptosis and atrophy of the mammary tissue

Common post-operative nutritional problems

Nausea Vomiting Dehydration Frothing Diarrhea Dumping Syndrome Dizziness Bad Breath Loss of appetite Food gettingrdquostuckrdquo

Hair Loss Lactose intolerance Vitaminmineral deficiencies Protein malnutrition Food intolerances Food aversionsfears Depression often caused by frustration around inability to eat for

comfortstress ldquoHibernation ldquo Syndrome

Late post ndashoperative complicationWeight Gain

Grazing Snacking on left ndashover meals Hidden calories Alcohol Poor food choices Carbonated beverages Lack of exercise Failure to check weight regularly Not attending follow up visits with Bariatric Surgeon

Post-Op Monitoring

Follow-up Lab Tests

Every 3 months for the first year

CBC glucose creatinine

Every 6 months for the first year

LFTs protein and albumin iron TIBC ferritin vitamin B12 folic acid calcium parathyroid hormone (if hypercalcemic)

Every year after the first year All of the above

Importance of Aftercare

Surgery is only the beginning Initially the ldquofull time jobrdquo is learning to eat Team approach to follow up you are an important player Primary goal is to maintain good nutrition ldquoKeep folks on the roadrdquo

Long-Term ComplicationsSide Effects ndash Skin Issues

Severe infection of the excess abdominal skin

Treat with antibiotics and skin hygiene

Consider excision of the excess skin

The most common areas subject to plastic surgery procedures are the abdomen thighs and buttocks

These areas are very susceptible to treatment with a combination of liposuction and body lifting procedures

When the face and the neck are involved the surgical corrections follow the same principle of liftingtightening the skin and subdermal tissues

Mastopexy or breast lift is also a very common procedure as patients almost universally complain of ptosis and atrophy of the mammary tissue

Late post ndashoperative complicationWeight Gain

Grazing Snacking on left ndashover meals Hidden calories Alcohol Poor food choices Carbonated beverages Lack of exercise Failure to check weight regularly Not attending follow up visits with Bariatric Surgeon

Post-Op Monitoring

Follow-up Lab Tests

Every 3 months for the first year

CBC glucose creatinine

Every 6 months for the first year

LFTs protein and albumin iron TIBC ferritin vitamin B12 folic acid calcium parathyroid hormone (if hypercalcemic)

Every year after the first year All of the above

Importance of Aftercare

Surgery is only the beginning Initially the ldquofull time jobrdquo is learning to eat Team approach to follow up you are an important player Primary goal is to maintain good nutrition ldquoKeep folks on the roadrdquo

Long-Term ComplicationsSide Effects ndash Skin Issues

Severe infection of the excess abdominal skin

Treat with antibiotics and skin hygiene

Consider excision of the excess skin

The most common areas subject to plastic surgery procedures are the abdomen thighs and buttocks

These areas are very susceptible to treatment with a combination of liposuction and body lifting procedures

When the face and the neck are involved the surgical corrections follow the same principle of liftingtightening the skin and subdermal tissues

Mastopexy or breast lift is also a very common procedure as patients almost universally complain of ptosis and atrophy of the mammary tissue

Post-Op Monitoring

Follow-up Lab Tests

Every 3 months for the first year

CBC glucose creatinine

Every 6 months for the first year

LFTs protein and albumin iron TIBC ferritin vitamin B12 folic acid calcium parathyroid hormone (if hypercalcemic)

Every year after the first year All of the above

Importance of Aftercare

Surgery is only the beginning Initially the ldquofull time jobrdquo is learning to eat Team approach to follow up you are an important player Primary goal is to maintain good nutrition ldquoKeep folks on the roadrdquo

Long-Term ComplicationsSide Effects ndash Skin Issues

Severe infection of the excess abdominal skin

Treat with antibiotics and skin hygiene

Consider excision of the excess skin

The most common areas subject to plastic surgery procedures are the abdomen thighs and buttocks

These areas are very susceptible to treatment with a combination of liposuction and body lifting procedures

When the face and the neck are involved the surgical corrections follow the same principle of liftingtightening the skin and subdermal tissues

Mastopexy or breast lift is also a very common procedure as patients almost universally complain of ptosis and atrophy of the mammary tissue

Importance of Aftercare

Surgery is only the beginning Initially the ldquofull time jobrdquo is learning to eat Team approach to follow up you are an important player Primary goal is to maintain good nutrition ldquoKeep folks on the roadrdquo

Long-Term ComplicationsSide Effects ndash Skin Issues

Severe infection of the excess abdominal skin

Treat with antibiotics and skin hygiene

Consider excision of the excess skin

The most common areas subject to plastic surgery procedures are the abdomen thighs and buttocks

These areas are very susceptible to treatment with a combination of liposuction and body lifting procedures

When the face and the neck are involved the surgical corrections follow the same principle of liftingtightening the skin and subdermal tissues

Mastopexy or breast lift is also a very common procedure as patients almost universally complain of ptosis and atrophy of the mammary tissue

Long-Term ComplicationsSide Effects ndash Skin Issues

Severe infection of the excess abdominal skin

Treat with antibiotics and skin hygiene

Consider excision of the excess skin

The most common areas subject to plastic surgery procedures are the abdomen thighs and buttocks

These areas are very susceptible to treatment with a combination of liposuction and body lifting procedures

When the face and the neck are involved the surgical corrections follow the same principle of liftingtightening the skin and subdermal tissues

Mastopexy or breast lift is also a very common procedure as patients almost universally complain of ptosis and atrophy of the mammary tissue

The most common areas subject to plastic surgery procedures are the abdomen thighs and buttocks

These areas are very susceptible to treatment with a combination of liposuction and body lifting procedures

When the face and the neck are involved the surgical corrections follow the same principle of liftingtightening the skin and subdermal tissues

Mastopexy or breast lift is also a very common procedure as patients almost universally complain of ptosis and atrophy of the mammary tissue

Success of Surgical Treatment

ASBS 2000

Conclusion

Bariatric surgery is the only effective long term treatment for morbid obesity

Evidence for its initial amp medium term success is overwhelming Extension of principles of surgery for obesity to other metabolic

conditions especially type2 DM will increase its usage There is no ideal bariatric surgery as it varies from patient to patient

no long term studies Newer techniques for performing this type of surgery promise to offer

less complications less invasive surgery amp better outcomes

Thank You

• BARIATRIC SURGERY
• Introduction
• Bariatric Surgery
• introduction
• Slide 5
• Degrees of Obesity
• Obesity grading and assessment in Western and Asian Population
• Prevalence of Obesity
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Etiology of Obesity
• Pathophysiology Of Obesity
• Slide 16
• Medical Complications of Obesity
• What are your options
• Guidelines for the Treatment of Overweight and Obese Individual
• Indications for drug treatment
• Obesity Drugs
• Sibutramine (Meridia)
• Orlistat
• Side Effects
• Why Diets Often Fail
• Why Surgery
• Slide 27
• Who Is a Surgical Candidate
• Recommended BMI values for Bariatric Surgery in Asians
• Slide 30
• Obesity multidisciplinary team
• Bariatric Surgery and Diabetes
• Contraindications
• Preoperative Evaluation
• Investigationshellip
• Concurrent Preoperative and Prophylactic Medications
• DVT consideration
• What Are the Risks
• History of Bariatric Surgery
• How does surgery work
• Laparoscopic vs Open
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• How does the Band work
• LAP-BAND Adjustability
• Slide 50
• Slide 51
• Advantages
• Comparison of Adjustable Gastric Banding and Vertical Banded Ga
• Slide 54
• Slide 55
• SLEEVE GASTRECTOMY
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• ENDO BARRIER LINER SYSTEM
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• How Does the Roux-en-Y Work
• Slide 71
• Slide 72
• Biliopancreatic Diversion (BPD)
• Biliopancreatic Diversion with Duodenal Switch
• Slide 75
• Slide 76
• Effect of Bariatric Surgery on Diabetes Mellitus
• Combined Gastric Restriction amp Malabsorption
• Slide 79
• Slide 80
• Anastamosis Leaks
• Anastamosis Leaks (2)
• Pulmonary Embolism
• Pulmonary Embolism (2)
• Cholelithiasis
• Stomal Ulceration
• Stomal Ulceration (2)
• Dumping Syndrome
• Dumping Syndrome (2)
• Constipation
• Nutritional Consequences
• Iron deficiency and anemia
• Vitamin B12 deficiency
• Folate Deficiency
• Vitamin D and Calcium Deficiency
• Nutritional Implications of Various Bariatric Surgeries(34)
• Recommended Daily Supplements(4)
• Diet Recommendations(3)
• Diet Progression Gastric Bypass
• Diet Progression Lap - Band
• Stage 1
• Protein supplements
• Vitamin and Mineral Supplements
• Vitamin and Mineral Supplements (2)
• Stage 2 diet
• Puree diet
• Stage 3 diet
• Stage 3 diet
• Stage 3 continued
• Common post-operative nutritional problems
• Late post ndashoperative complication Weight Gain
• Post-Op Monitoring
• Importance of Aftercare
• Long-Term Complications Side Effects ndash Skin Issues
• Slide 115
• Slide 116
• Conclusion
• Thank You

Conclusion

Bariatric surgery is the only effective long term treatment for morbid obesity

Evidence for its initial amp medium term success is overwhelming Extension of principles of surgery for obesity to other metabolic

conditions especially type2 DM will increase its usage There is no ideal bariatric surgery as it varies from patient to patient

no long term studies Newer techniques for performing this type of surgery promise to offer

less complications less invasive surgery amp better outcomes

Thank You

• BARIATRIC SURGERY
• Introduction
• Bariatric Surgery
• introduction
• Slide 5
• Degrees of Obesity
• Obesity grading and assessment in Western and Asian Population
• Prevalence of Obesity
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Etiology of Obesity
• Pathophysiology Of Obesity
• Slide 16
• Medical Complications of Obesity
• What are your options
• Guidelines for the Treatment of Overweight and Obese Individual
• Indications for drug treatment
• Obesity Drugs
• Sibutramine (Meridia)
• Orlistat
• Side Effects
• Why Diets Often Fail
• Why Surgery
• Slide 27
• Who Is a Surgical Candidate
• Recommended BMI values for Bariatric Surgery in Asians
• Slide 30
• Obesity multidisciplinary team
• Bariatric Surgery and Diabetes
• Contraindications
• Preoperative Evaluation
• Investigationshellip
• Concurrent Preoperative and Prophylactic Medications
• DVT consideration
• What Are the Risks
• History of Bariatric Surgery
• How does surgery work
• Laparoscopic vs Open
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• How does the Band work
• LAP-BAND Adjustability
• Slide 50
• Slide 51
• Advantages
• Comparison of Adjustable Gastric Banding and Vertical Banded Ga
• Slide 54
• Slide 55
• SLEEVE GASTRECTOMY
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• ENDO BARRIER LINER SYSTEM
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• How Does the Roux-en-Y Work
• Slide 71
• Slide 72
• Biliopancreatic Diversion (BPD)
• Biliopancreatic Diversion with Duodenal Switch
• Slide 75
• Slide 76
• Effect of Bariatric Surgery on Diabetes Mellitus
• Combined Gastric Restriction amp Malabsorption
• Slide 79
• Slide 80
• Anastamosis Leaks
• Anastamosis Leaks (2)
• Pulmonary Embolism
• Pulmonary Embolism (2)
• Cholelithiasis
• Stomal Ulceration
• Stomal Ulceration (2)
• Dumping Syndrome
• Dumping Syndrome (2)
• Constipation
• Nutritional Consequences
• Iron deficiency and anemia
• Vitamin B12 deficiency
• Folate Deficiency
• Vitamin D and Calcium Deficiency
• Nutritional Implications of Various Bariatric Surgeries(34)
• Recommended Daily Supplements(4)
• Diet Recommendations(3)
• Diet Progression Gastric Bypass
• Diet Progression Lap - Band
• Stage 1
• Protein supplements
• Vitamin and Mineral Supplements
• Vitamin and Mineral Supplements (2)
• Stage 2 diet
• Puree diet
• Stage 3 diet
• Stage 3 diet
• Stage 3 continued
• Common post-operative nutritional problems
• Late post ndashoperative complication Weight Gain
• Post-Op Monitoring
• Importance of Aftercare
• Long-Term Complications Side Effects ndash Skin Issues
• Slide 115
• Slide 116
• Conclusion
• Thank You

Thank You

• BARIATRIC SURGERY
• Introduction
• Bariatric Surgery
• introduction
• Slide 5
• Degrees of Obesity
• Obesity grading and assessment in Western and Asian Population
• Prevalence of Obesity
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Etiology of Obesity
• Pathophysiology Of Obesity
• Slide 16
• Medical Complications of Obesity
• What are your options
• Guidelines for the Treatment of Overweight and Obese Individual
• Indications for drug treatment
• Obesity Drugs
• Sibutramine (Meridia)
• Orlistat
• Side Effects
• Why Diets Often Fail
• Why Surgery
• Slide 27
• Who Is a Surgical Candidate
• Recommended BMI values for Bariatric Surgery in Asians
• Slide 30
• Obesity multidisciplinary team
• Bariatric Surgery and Diabetes
• Contraindications
• Preoperative Evaluation
• Investigationshellip
• Concurrent Preoperative and Prophylactic Medications
• DVT consideration
• What Are the Risks
• History of Bariatric Surgery
• How does surgery work
• Laparoscopic vs Open
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Slide 47
• How does the Band work
• LAP-BAND Adjustability
• Slide 50
• Slide 51
• Advantages
• Comparison of Adjustable Gastric Banding and Vertical Banded Ga
• Slide 54
• Slide 55
• SLEEVE GASTRECTOMY
• Slide 57
• Slide 58
• Slide 59
• Slide 60
• Slide 61
• ENDO BARRIER LINER SYSTEM
• Slide 63
• Slide 64
• Slide 65
• Slide 66
• Slide 67
• Slide 68
• Slide 69
• How Does the Roux-en-Y Work
• Slide 71
• Slide 72
• Biliopancreatic Diversion (BPD)
• Biliopancreatic Diversion with Duodenal Switch
• Slide 75
• Slide 76
• Effect of Bariatric Surgery on Diabetes Mellitus
• Combined Gastric Restriction amp Malabsorption
• Slide 79
• Slide 80
• Anastamosis Leaks
• Anastamosis Leaks (2)
• Pulmonary Embolism
• Pulmonary Embolism (2)
• Cholelithiasis
• Stomal Ulceration
• Stomal Ulceration (2)
• Dumping Syndrome
• Dumping Syndrome (2)
• Constipation
• Nutritional Consequences
• Iron deficiency and anemia
• Vitamin B12 deficiency
• Folate Deficiency
• Vitamin D and Calcium Deficiency
• Nutritional Implications of Various Bariatric Surgeries(34)
• Recommended Daily Supplements(4)
• Diet Recommendations(3)
• Diet Progression Gastric Bypass
• Diet Progression Lap - Band
• Stage 1
• Protein supplements
• Vitamin and Mineral Supplements
• Vitamin and Mineral Supplements (2)
• Stage 2 diet
• Puree diet
• Stage 3 diet
• Stage 3 diet
• Stage 3 continued
• Common post-operative nutritional problems
• Late post ndashoperative complication Weight Gain
• Post-Op Monitoring
• Importance of Aftercare
• Long-Term Complications Side Effects ndash Skin Issues
• Slide 115
• Slide 116
• Conclusion
• Thank You