how to choose the best bariatric metabolic … · 2018. 8. 23. · how to choose the best bariatric...
TRANSCRIPT
HOW TO CHOOSE THE BEST BARIATRIC METABOLIC PROCEDURE FOR YOUR PATIENT
Established vs the Novel
MAL Fobi MD FACS FICS FACNClinical Professor of Surgery SAIMS JIO University
ampDirector of Training and Research
MOHAK Bariatric and Robotic Surgery Center Indore India
Past President California Chapter ASMBS
Past president of the ASMBS Foundation
Past President of IFSO
Past Chairman of the Board of Trustees of IFSO
MOHAK BARIATRIC AND ROBOTIC SURGERY
CENTER(MBRSC) INDORE INDIA
SAIMS JIO UNIVERSITY CAMPUS INDORE INDIA
GREETINGS FROM
DISCLOSURESFounding President of Bariatec
Corporation that produces the
MSRtrade and GaBP Ringtrade devices
I had the Ring Banded
Gastric Bypass April 8 2011
to control Type 2 diabetes
Complete remission of
Diabetes with Loss and
maintenance of 58 lbs for
seven years
BMI 314 ----242
Hb A-1c 94---64
Blood glucose lt100
Sleep Apnea- resolved
Arthritis-resolved
Increased energy level
CHOICE OF PROCEDURE
RYGB MGBOAGB LSG
2671 3599 2775
LGB 1720
BGB 454
RobGB 346
SILGB 151
MGB 2671BMGB 134
RobMGB 595
SILMGB 199
LSG 1907
BSG 224
RobSG 130
SILS 514
CHOICE OF PROCEDURE
CASE MIX DISCLOSURE
CHOICE OF PROCEDURE
lsquoThose who cannot learn from the past
are condemned to repeat itrsquo
George Santayana
History doesnt repeat itself
but it does rhymerdquo
Mark Twain
CHOICE OF PROCEDURE
Obesity is a multifactorialmultisystem and life longdisease with medicalpsychological physicaleconomic and socialramifications
Any Treatment at bestprovides remission andamelioration not a cure
Choice of Operation
PharmacotherapyDietingPhysical exerciseBehavioral modificationPsychotherapySurgical intervention
Treatment Options
Choice of Operation
PharmacotherapyDietingPhysical exerciseBehavioral modificationPsychotherapy
Treatment Options
Without surgery these options individually or in combination result in a high recidivism rate
CHOICE OF PROCEDURE
PharmacotherapyDietingPhysical exerciseBehavioral modificationPsychotherapySurgical intervention
A multidisciplinary approach including Surgical intervention provides the only long term option for treatment of obesity
TREATMENT OPTIONS
CHOICE OF PROCEDURE
ARMAMENTARIUM OF BARIATRIC METABOLIC PROCEDURES
bull The least effective current surgical
operation is many fold more effective
than any known non surgical treatment
SOS
Study
What we have learnt thus far
CHOICE OF PROCEDURE
CHOICE OF PROCEDURE
WHAT WE HAVE LEARNT THUS FAR
No one operation fits the needs of all patients
Choice of Operation
1 We currently have a better understanding of the Disease entity Obesity and the determining factors that affect the treatment of obesity
2 Mechanisms of action of various bariatric metabolic operations
AND
3 We know more about the operations---the relative contra-indications and the short and long-term outcomes of the various procedures
CHOICE OF PROCEDURE
THE DISEASE OBESITY
CHOICE OF PROCEDURE
THE DISEASE OBESITY
Obesity is a multi-system disease
Determining factors in the obese that affect the outcome of operations
Co morbid conditions
Risk factors in surgical treatment of obesity
CHOICE OF PROCEDURE
DETERMINING FACTORS
Genetics Expression of ObesityResponse to surgical treatment
Medical Metabolic syndrome T2DM CAD HO VTE Presence or absence of GERD Liver status and Mental Illness
Patient profile BMI Age GenderSocio-psycho-economic Factors
Smoking Alcohol intake Access to post op care Distance from care provider Cost of the operation-Cost and availability of equipment devices and suppliesAffordability of post operative care-Supplements-educational-financial status
DemographicEnvironmental factorsVegetarianAreas endemic to certain problemsmdashCancer UlcersCultural norms
MECHANISMS OF ACTION OF VARIOUS BARIATRIC METABOLIC OPERATIONS
bull Restrictive Effect Control the reservoir size
bull Neural Stimulation of G-E full sense effectsatiation
bull Patient Compliance Forced behavior modification Motivation fear dyspepsia physical activity dietary habit alteration support group participation and physician contact
bull Malabsorptive Effect Bypassed segment of the GI tract results in mal absorption
bull Dumping Effect High caloric fluid and fatty food intolerance
bull Ghrelin Effect Anorexia
bull Foregut effect GIP PYY and Leptin effects
bull Hindgut effect GLP-I motilityNauseasatiation
bull Microbiota effect alteration of the bacterial flora of the gut alters absorption
bull Bile salts
CHOICE OF PROCEDURE
Currently known mechanisms responsible for the effects of the various bariatric metabolic operations include but not limited to
Outcomes of the various operationsWeight Loss and maintenanceResolution of co-morbid conditions---Contra-indications to the various operations--Complications inherent in the operations----
CHOICE OF PROCEDURE
bull Refluxbull Ulcersbull Nutrient deficienciesbull Protein caloric malnutritionbull DiarrheaSteatorrheabull Food Intolerancebull RingBand Migration
The Operations and Procedures
SURGICAL TREATMENT OPTIONS
A Bariatric Metabolic Surgeon should be able to Perform these three basic procedures and their modifications
Sleeve Gastrectomy Gastric Bypass OAGBMGB
CHOICE OF PROCEDURE
CHOICE OF PROCEDURE
Sleeve Gastrectomy Ring BandedSleeve Gastrectomy
The Ring Stabilizes The Size of The Sleeveand minimizes the disadvantagesSEEVE GASTRECTOMY
1 Relatively simple operation2 No disruption of gastrointestinal tract3 No gastro-intestinal anastomosis4 Nearly regular intestinal absorption 5 Low incidence of dumping syndrome6 0 risk of developing an internal hernia 7 Good weight loss and resolution of
co-morbid conditions almost equal to GBP
Disadvantages-Weight loss ltLGBP-Dilation of sleeve with weight regain and recurrence of co-morbid conditions
-Neo-reflux-Intractable leaks-Torsionstenosis-Porto-mesenteric thrombosis
CHOICE OF PROCEDURE
Sleeve Gastrectomy
Ring BandedSleeve Gastrectomy
06M 1 yr 2yr 3yr 4yr 5yr 6yr
EB
WL
Follow UP
p vs Baseline always lt0001 BSG LSG
Bhandari M Mathur W etal In Print SOARD
CHOICE OF PROCEDURE
THREE YEARS SIX YEARS
THREE YEARS SIX YEARSLess than 50 50-75 above75 Less than 50 50-75 above75
BSG (0) 0 (2) 35 (56) 965 (0) 0 (4) 83 (44) 917
LSG (15)111 (66)474 (53)395 (46)469 (46)469 (9)91
0102030405060708090
100
BSG
LSG
3 YEARSLSG 111BSG 0
FAILURE RATE
6 YEARSLSG 469BSG 0
CHOICE OF PROCEDURE
CHOICE OF PROCEDURE
Bhandari M Mathur W Mishra A MBRSC Course May 2017 Indore India
The Gastric Bypass is the Gold Standard of Bariatric Metabolic Operations
RGBP BGBP
CHOICE OF PROCEDURE
COMPARISON OF BGBP VS STD GBP
Outcome after the operations BGBP STD GBP
Av Initial weight loss 1-3yrs gt77 65-70
Weight loss 4-10 years 70-77 55-65
Resolution of T2DM 80--85 60-80
VomitingSolid Food Intolerance 5-15 lt5
Significant Weight regain 3-7 10-35
Ringband Erosion 0-2 NA
CHOICE OF PROCEDURE
OAGBPMGB
One Anastamosis Gastric BypassMini Gastric Bypass (OAGBMGB)
Simplicity
Repeatability
Minimal Dissection
Reversibility
Exit Strategy
Safety
Minimal Suturing
Short Duration
Short Learning Curve
CHOICE OF PROCEDURE
OAGBSAGBMGB Advantagesbull Easier operation compared to Standard GBPbull Better food tolerancebull More weight loss than standard GBPbull Better weigh Loss Maintenancebull Higher metabolic effect on T2DM and Hyperlipidemiabull Less incidence of internal herniabull More options for revision if needed
Disadvantagesbull Bile reflux gastritis and esophagitisbull Marginal ulcersbull Nutrient deficienciesbull Protein Caloric Malnutrition
Quan Y Huanh A Ye M Efficacy of laproscopic mini gastric bypass for obesity and type 2 diabetes mellitus A systematic review and met-analysis Gastroenterol Res Pract 2015 ID 152852 10155
CHOICE OF PROCEDURE
2015 ndash Review articleVictorzon M et al Scand J Surg 2015 Mar104(1)48-53 Single-anastomosis gastric
bypass better faster and safer
bull The abstracts of 73 articles were reviewed and after removal of case studies duplicates and irrelevant articles 10 articles remained for closer review
bull Several thousand of this operation have been performed for more than 15 years It is claimed to be an easier safer faster and more effective metabolic operation compared to the standard Roux-en-Y gastric bypass The proponents of this operation also claim that this operation is easier to revise and reverse leaving more options compared to the situation after standard bypass in case of failure However there is much controversy surrounding this method mainly concerning the possible harmful and in the long-term even carcinogenic effects of biliopancreaticoduodenal reflux in the gastric pouch
Comment
Several thousands MGBs performed over 15 yrsEasier safer faster amp more effective than
RYGBEasier to revise amp reverse
Controversy regarding carcinogenic effect of BPD reflux
1306
1213
1294
1218
131
1207
114
116
118
12
122
124
126
128
13
132
Before After
BGB LGB MGB
Hemoglobin
RYGB VS Banded RYGB VS OAGBMGB
CHOICE OF PROCEDURE
399
372
394
36
396
352
32
33
34
35
36
37
38
39
4
41
Before After
BGB LGB MGB
Albumin661
644
693
67
685
607
56
58
6
62
64
66
68
7
Before After
BGB LGB MGB
Protein
RYGB VS Banded RYGB VS OAGBMGB
CHOICE OF PROCEDURE
911
87
906
873
909
833
78
8
82
84
86
88
9
92
Before After
BGB LGB MGB
Calcium
CHOICE OF PROCEDURE
RYGB VS Banded RYGB VS OAGBMGB
COMPARISON OF BGBP OAGB VS STD GBP
Outcome after the operations BGBP OAGBP STD GBP
Av Initial weight loss 1-3yrs gt77 gt77 65-70
Weight loss 4-10 years 70-77 70-77 55-65
Resolution of T2DM 80--85 80-90 60-80
VomitingSolid Food Intolerance 5-15 lt5 lt5
Diarrhea and Steatorrhea 1-2A 15-30 NA
Symptomatic Reflux 1-3 3-11 1-3
Marginal Ulcers 3-5 3-5 3-5
Protein Caloric Malnutrition lt1 3-11 lt1
Significant Weight regain 3-10 3-10 10-35
Ringband Erosion 0-1 NA NA
CHOICE OF PROCEDURE
We have enough information currently to enhance the outcome and minimize the risk by matching the operation to the patient
That is the basis forAn Algorithm for Bariatric Metabolic Operations
CHOOSING THE BEST BARIATRIC METABOLIC PROCEDURE FOR THE PATIENT
CHOICE OF PROCEDURE
bull All agesbull With no diabetesbull With low BMI preferably lt40bull With no GERDbull With HO PUDbull With HO or findings of liver diseasebull With Inflammatory bowel diseasebull With dense adhesions from multiple small bowel surgeriesbull Without HO VTEbull In heavy smokers who are not likely to quitbull In gastric cancer endemic areasbull High Risk needing minimal anesthesia and OR timebull High BMI gt 60 as part of a two stage approach
ALGORITHM
LSG BSG
CHOICE OF PROCEDURE
Laparoscopic Sleeve Gastrectomy Or Banded Sleeve Gastrostomy (SGBSD) Indicated for Patients
-All ages-Patients with T2DM lt5years and HbA1-c lt8 C-Peptidegt2 and not on insulin
-Patients with GERD
-ALL BMI ----- -BGBPBMIlt50-- LGBP
Vegetarian (BGBP)
BGBPLGBP
CHOICE OF PROCEDURE
ALGORITHM
Laparoscopic Gastric Bypass(LGBP) or Banded Gastric Bypass(BGBP) Indicated for Patients
bull With Diabetes gt5 years HbA1cgt8 C-Peptide lt2andor on Insulinbull All agesbull All BMI particularly High BMI-gt50bull High risk patients with need for short anesthesia timebull Because it is an easy to perform procedurebull Best tolerated by non Vegetarian
bull GERD Is a contraindicationbull Liver disease is a contraindication
Must be able to follow up patient regularlyPatient must be able to afford the required supplements OAGB
CHOICE OF PROCEDURE
ALGORITHM
OAGBMGB for patients
Sleeve gastrectomy with duodenal bypass(SGDJB) in patients with indication for Gastric Bypass in Gastric Cancer Endemic Areas
As effective as GBPSame weight loss andmetabolic effects as gastric bypass
SG-DJB
CHOICE OF PROCEDURE
ALGORITHM
Sleeve gastrectomy with duodenal bypass(SGDJB) in patients
1Second stage operation for the sleeve gastrectomy
2 Non responders or complications of sleeve gastric bypass or OAGBMGB
BPD-DS SADI SASI SG with enteral bypass
CHOICE OF PROCEDURE
ALGORITHM
BPD-DS SADI SAGI SASI) Indicated for
Areas with high incidence of anemia and very strict vegetarian food habits
CHOICE OF PROCEDURE
ALGORITHM
Sleeve Gastrectomy with gastro-jejunal gastro-ileal or entero-enteral anastomosis
Intra Gastric Balloon ENDOBARRIER
V-BLOC Aspire AssistEndoscopic Plication
For a patient who does not want an intra abdominal gastro-intestinal procedure
CHOICE OF PROCEDURE
Should You Do A Bariatric Metabolic Operation Because That Is What The Patient Wantsrdquo
NOYESmdashIt depends HoweverA bariatric metabolic surgeon should be able to offer the best operation for the patient based on the patientrsquos profile It is good practice to refer the patient to a tertiary center if the surgeon does not offer the operation that meets the patients indication
CHOICE OF PROCEDURE
CHOOSING THE BEST BARIATRIC METABOLIC PROCEDURE FOR THE PATIENT
CHOICE OF PROCEDURE
Case 157 yo Male BMI 57KgM2 T2DM GERD Strict Vegetarian
Algorithm
Gastric bypass-----Preferably Banded gastric bypassmdash------GERD Vegetarian
Not Sleeve because of T2DM GERD and High BMI
Not OAGBMGB because of GERD and probable of protein deficiency
CHOOSING THE BEST BARIATRIC METABOLIC PROCEDURE FOR THE PATIENT
CHOICE OF PROCEDURE
Case 1128 y0 F BMI 42 PCO DUB OSA and HO Migraine headaches
AlgorithmSleeve GastrectomymdashPreferably a Ring banded Sleeve gastrectomy
----No T2DM---No GERDNot Gastric bypass mdash anemia smelly flatus
Not OAGBMGB----Anemia Foul smelling flatus and body odor----Protein deficiency
CHOOSING THE BEST BARIATRIC METABOLIC PROCEDURE FOR THE PATIENT
CHOICE OF PROCEDURE
Case 11137 yo Male BMI 68 OSA OA and a non vegetarian who works at your hospitalReferred by the pulmonologist at your medical Centre
Algorithm
OAGBMGBmdashHigh BMI Non Veg-better food tolerance patient very likely to be followedand to afford the supplements because of proximity to your center
Not sleeve---poor weight loss with sleeve in super obeseNot Banded sleeve---Good weight loss but poor food tolerance since patient is a non vegetarianNot Gastric bypass---Weight loss in super obese have high non response after gastric bypass
and the gastric bypass is technically a more difficult operation than the OAGBNot Banded gastric bypass ndashGood weight loss but a BGBP is a more difficult operation and
the patient will have some food intolerance because of the ring
SURGICAL TREATMENT OPTIONS
At Mohak we perform these standard three operations and their banded modifications
Sleeve Gastrectomy Gastric Bypass OAGBMGB
CHOICE OF PROCEDURE
Evidence based operations performed at MBRSC From 2010 t0 2017---Standardized OperationsLaparoscopic Sleeve Gastrectomybull 90-120 cc Sleevebull 2-5cm from pylorusbull Where a sleeve is indicated but a band is contraindicated or not affordableBanded Sleeve Gastrectomy (BSG) 84 EWL after 60 monthsbull 90-120 cc Sleevebull 2-5cm from pylorusbull Ring 65-75 cmbull At 3-6 cm below GE junctionBanded Gastric bypass (BGBP) 75 EWL 48 monthsbull Create 6mdash7cm long pouchbull 65-75 cm ring at 3-5 cm below GE junction and gt2cm above anastomosisbull Large Gastroenterostomy gt 2cm bull 100cm Roux Limb and 80 cm BP limb for BMIlt50bull 100cm Roux Limb and 150 cm BP limb for BMIgt50Mini-Gastric Bypass (MGB) (OAGB) 79 EWL 60 monthsbull 9-18cm long pouch ~25cm widebull BP Limb length of 180cm BMIlt50Banded Mini-Gastric Bypass(BMGB)(BOAGB)bull 9-18cm long pouch ~25cm widebull Ring 7-75 cmbull BP Limb length of 180cm BMI50
THE MOHAK PROTOCOLStandardized Bariatric and Robotic Surgery Operations
CHOICE OF PROCEDURE
Sleeve Gastrectomy (LSG) or Banded Sleeve Gastrectomy (BSG)bull Non-diabeticsbull No hiatal hernia or GERDbull HO Smokingbull HO alcohol usebull HO PUDbull Abnormal LFTs NASH and early Cirrhosisbull Pts from areas with high incidence of gastric cancer of H pylori infectionbull High risks patients and super obese patients as part of a two-staged operation
Gastric Bypass (LGBP) or Banded Gastric Bypass (BGBP) or Hybrid BGBPMGBbull Have T2DM with HgbA1c lt 8 and duration lt 5 yearsbull Have Hiatal hernia or GERDbull Are Vegetarianbull No nicotine addiction (smoking)bull Have HO Alcohol intake bull Have NASH at surgery-No cirrhosisbull Not likely to come back for follow up andbull Revision operation of Failed Sleeve gastrectomy GBP or MGB
MOHAK ALGORITHM
CHOICE OF PROCEDURE
One Anastomosis Gastric Bypass-Mini-Gastric Bypass (OAGBP-MGB) bull Have T2DM with HgbA1c 8 and durationgt5 yearsbull Have No GERDbull Are Non-vegetarianbull Have poor dentitionbull Most likely to return for follow up at the clinicbull No HO alcohol intakebull No Nicotine addiction (smoking)bull Normal LFTsbull No NASH at surgery or cirrhosisbull Commitment by our program to have 100 follow up of theses patient
Revision Operationbull Sleeve to Banded RY with 100 cm Al limb and 180 cm BP Limbbull MGB to diverted MGB for Reflux Existing BPL and 100cm ALbull MGB to GBP for PCM or reversal to normal anatomy for PCMmdashinterim gastrostomy feedingbull GBP to BGBP with 180cm BP limb for Weight regain or inadequate weight loss BMIlt40bull GBP to BGBP with 300cm common limb for Weight regain or inadequate weight loss BMIgt40
MOHAK ALGORITHM
CHOICE OF PROCEDURE
bull Laparoscopic Gastric Bypass
bull Laparoscopic Sleeve Gastrectomy
bull Divided Mini-Gastric Bypass
bull Biliopancreatic Diversion with DS
bull Single Anastomosis Duodeno-ileostomy
bull Gastric Plication
bull Banded Gastric Plication
bull Endoscopic Gastroplasty
bull Laparoscopic Adjustable Gastric bands
bull Balloon Implantation
bull Ileal interposition
These other operations will be used selectively based on patients needs and the surgeons determination
CHOICE OF PROCEDURE
The MOHAK Guide for Choice of Bariatric Metabolic Surgery Operations
Single Incision Laparoscopic Robotic and Endoscopic approaches are
available at patientsrsquo requests and the discretion of the surgeon
CHOICE OF PROCEDURE
The MOHAK Guide for Choice of Bariatric Metabolic Surgery Operations
Mohak Bariatrics and Robotics Surgery Center Motto
ldquoThe best operation for the patient by a competent surgeon in a well equipped hospital to maximize outcomes with the least amount of risks exposurerdquo
WE ARE ABLE TO CHOOSE THE BEST BARIATRIC METABOLIC PROCEDURE FOR YOUR PATIENT
Good long-term results are our marketing toolSuccessful patients make a lot of referralsbull
CHOICE OF PROCEDURE
The MOHAK Guide for Choice of Bariatric Metabolic Surgery Operations
We offer various treatment modalities for obesity The operation is
determined by the profile of the patient and guided by findings from
analysis of the data from our prospectively maintained database
MOHAK TEAM INDORE INDIA
THANK YOU
MOHAK BARIATRIC AND ROBOTIC SURGERY
CENTER(MBRSC) INDORE INDIA
SAIMS JIO UNIVERSITY CAMPUS INDORE INDIA
GREETINGS FROM
DISCLOSURESFounding President of Bariatec
Corporation that produces the
MSRtrade and GaBP Ringtrade devices
I had the Ring Banded
Gastric Bypass April 8 2011
to control Type 2 diabetes
Complete remission of
Diabetes with Loss and
maintenance of 58 lbs for
seven years
BMI 314 ----242
Hb A-1c 94---64
Blood glucose lt100
Sleep Apnea- resolved
Arthritis-resolved
Increased energy level
CHOICE OF PROCEDURE
RYGB MGBOAGB LSG
2671 3599 2775
LGB 1720
BGB 454
RobGB 346
SILGB 151
MGB 2671BMGB 134
RobMGB 595
SILMGB 199
LSG 1907
BSG 224
RobSG 130
SILS 514
CHOICE OF PROCEDURE
CASE MIX DISCLOSURE
CHOICE OF PROCEDURE
lsquoThose who cannot learn from the past
are condemned to repeat itrsquo
George Santayana
History doesnt repeat itself
but it does rhymerdquo
Mark Twain
CHOICE OF PROCEDURE
Obesity is a multifactorialmultisystem and life longdisease with medicalpsychological physicaleconomic and socialramifications
Any Treatment at bestprovides remission andamelioration not a cure
Choice of Operation
PharmacotherapyDietingPhysical exerciseBehavioral modificationPsychotherapySurgical intervention
Treatment Options
Choice of Operation
PharmacotherapyDietingPhysical exerciseBehavioral modificationPsychotherapy
Treatment Options
Without surgery these options individually or in combination result in a high recidivism rate
CHOICE OF PROCEDURE
PharmacotherapyDietingPhysical exerciseBehavioral modificationPsychotherapySurgical intervention
A multidisciplinary approach including Surgical intervention provides the only long term option for treatment of obesity
TREATMENT OPTIONS
CHOICE OF PROCEDURE
ARMAMENTARIUM OF BARIATRIC METABOLIC PROCEDURES
bull The least effective current surgical
operation is many fold more effective
than any known non surgical treatment
SOS
Study
What we have learnt thus far
CHOICE OF PROCEDURE
CHOICE OF PROCEDURE
WHAT WE HAVE LEARNT THUS FAR
No one operation fits the needs of all patients
Choice of Operation
1 We currently have a better understanding of the Disease entity Obesity and the determining factors that affect the treatment of obesity
2 Mechanisms of action of various bariatric metabolic operations
AND
3 We know more about the operations---the relative contra-indications and the short and long-term outcomes of the various procedures
CHOICE OF PROCEDURE
THE DISEASE OBESITY
CHOICE OF PROCEDURE
THE DISEASE OBESITY
Obesity is a multi-system disease
Determining factors in the obese that affect the outcome of operations
Co morbid conditions
Risk factors in surgical treatment of obesity
CHOICE OF PROCEDURE
DETERMINING FACTORS
Genetics Expression of ObesityResponse to surgical treatment
Medical Metabolic syndrome T2DM CAD HO VTE Presence or absence of GERD Liver status and Mental Illness
Patient profile BMI Age GenderSocio-psycho-economic Factors
Smoking Alcohol intake Access to post op care Distance from care provider Cost of the operation-Cost and availability of equipment devices and suppliesAffordability of post operative care-Supplements-educational-financial status
DemographicEnvironmental factorsVegetarianAreas endemic to certain problemsmdashCancer UlcersCultural norms
MECHANISMS OF ACTION OF VARIOUS BARIATRIC METABOLIC OPERATIONS
bull Restrictive Effect Control the reservoir size
bull Neural Stimulation of G-E full sense effectsatiation
bull Patient Compliance Forced behavior modification Motivation fear dyspepsia physical activity dietary habit alteration support group participation and physician contact
bull Malabsorptive Effect Bypassed segment of the GI tract results in mal absorption
bull Dumping Effect High caloric fluid and fatty food intolerance
bull Ghrelin Effect Anorexia
bull Foregut effect GIP PYY and Leptin effects
bull Hindgut effect GLP-I motilityNauseasatiation
bull Microbiota effect alteration of the bacterial flora of the gut alters absorption
bull Bile salts
CHOICE OF PROCEDURE
Currently known mechanisms responsible for the effects of the various bariatric metabolic operations include but not limited to
Outcomes of the various operationsWeight Loss and maintenanceResolution of co-morbid conditions---Contra-indications to the various operations--Complications inherent in the operations----
CHOICE OF PROCEDURE
bull Refluxbull Ulcersbull Nutrient deficienciesbull Protein caloric malnutritionbull DiarrheaSteatorrheabull Food Intolerancebull RingBand Migration
The Operations and Procedures
SURGICAL TREATMENT OPTIONS
A Bariatric Metabolic Surgeon should be able to Perform these three basic procedures and their modifications
Sleeve Gastrectomy Gastric Bypass OAGBMGB
CHOICE OF PROCEDURE
CHOICE OF PROCEDURE
Sleeve Gastrectomy Ring BandedSleeve Gastrectomy
The Ring Stabilizes The Size of The Sleeveand minimizes the disadvantagesSEEVE GASTRECTOMY
1 Relatively simple operation2 No disruption of gastrointestinal tract3 No gastro-intestinal anastomosis4 Nearly regular intestinal absorption 5 Low incidence of dumping syndrome6 0 risk of developing an internal hernia 7 Good weight loss and resolution of
co-morbid conditions almost equal to GBP
Disadvantages-Weight loss ltLGBP-Dilation of sleeve with weight regain and recurrence of co-morbid conditions
-Neo-reflux-Intractable leaks-Torsionstenosis-Porto-mesenteric thrombosis
CHOICE OF PROCEDURE
Sleeve Gastrectomy
Ring BandedSleeve Gastrectomy
06M 1 yr 2yr 3yr 4yr 5yr 6yr
EB
WL
Follow UP
p vs Baseline always lt0001 BSG LSG
Bhandari M Mathur W etal In Print SOARD
CHOICE OF PROCEDURE
THREE YEARS SIX YEARS
THREE YEARS SIX YEARSLess than 50 50-75 above75 Less than 50 50-75 above75
BSG (0) 0 (2) 35 (56) 965 (0) 0 (4) 83 (44) 917
LSG (15)111 (66)474 (53)395 (46)469 (46)469 (9)91
0102030405060708090
100
BSG
LSG
3 YEARSLSG 111BSG 0
FAILURE RATE
6 YEARSLSG 469BSG 0
CHOICE OF PROCEDURE
CHOICE OF PROCEDURE
Bhandari M Mathur W Mishra A MBRSC Course May 2017 Indore India
The Gastric Bypass is the Gold Standard of Bariatric Metabolic Operations
RGBP BGBP
CHOICE OF PROCEDURE
COMPARISON OF BGBP VS STD GBP
Outcome after the operations BGBP STD GBP
Av Initial weight loss 1-3yrs gt77 65-70
Weight loss 4-10 years 70-77 55-65
Resolution of T2DM 80--85 60-80
VomitingSolid Food Intolerance 5-15 lt5
Significant Weight regain 3-7 10-35
Ringband Erosion 0-2 NA
CHOICE OF PROCEDURE
OAGBPMGB
One Anastamosis Gastric BypassMini Gastric Bypass (OAGBMGB)
Simplicity
Repeatability
Minimal Dissection
Reversibility
Exit Strategy
Safety
Minimal Suturing
Short Duration
Short Learning Curve
CHOICE OF PROCEDURE
OAGBSAGBMGB Advantagesbull Easier operation compared to Standard GBPbull Better food tolerancebull More weight loss than standard GBPbull Better weigh Loss Maintenancebull Higher metabolic effect on T2DM and Hyperlipidemiabull Less incidence of internal herniabull More options for revision if needed
Disadvantagesbull Bile reflux gastritis and esophagitisbull Marginal ulcersbull Nutrient deficienciesbull Protein Caloric Malnutrition
Quan Y Huanh A Ye M Efficacy of laproscopic mini gastric bypass for obesity and type 2 diabetes mellitus A systematic review and met-analysis Gastroenterol Res Pract 2015 ID 152852 10155
CHOICE OF PROCEDURE
2015 ndash Review articleVictorzon M et al Scand J Surg 2015 Mar104(1)48-53 Single-anastomosis gastric
bypass better faster and safer
bull The abstracts of 73 articles were reviewed and after removal of case studies duplicates and irrelevant articles 10 articles remained for closer review
bull Several thousand of this operation have been performed for more than 15 years It is claimed to be an easier safer faster and more effective metabolic operation compared to the standard Roux-en-Y gastric bypass The proponents of this operation also claim that this operation is easier to revise and reverse leaving more options compared to the situation after standard bypass in case of failure However there is much controversy surrounding this method mainly concerning the possible harmful and in the long-term even carcinogenic effects of biliopancreaticoduodenal reflux in the gastric pouch
Comment
Several thousands MGBs performed over 15 yrsEasier safer faster amp more effective than
RYGBEasier to revise amp reverse
Controversy regarding carcinogenic effect of BPD reflux
1306
1213
1294
1218
131
1207
114
116
118
12
122
124
126
128
13
132
Before After
BGB LGB MGB
Hemoglobin
RYGB VS Banded RYGB VS OAGBMGB
CHOICE OF PROCEDURE
399
372
394
36
396
352
32
33
34
35
36
37
38
39
4
41
Before After
BGB LGB MGB
Albumin661
644
693
67
685
607
56
58
6
62
64
66
68
7
Before After
BGB LGB MGB
Protein
RYGB VS Banded RYGB VS OAGBMGB
CHOICE OF PROCEDURE
911
87
906
873
909
833
78
8
82
84
86
88
9
92
Before After
BGB LGB MGB
Calcium
CHOICE OF PROCEDURE
RYGB VS Banded RYGB VS OAGBMGB
COMPARISON OF BGBP OAGB VS STD GBP
Outcome after the operations BGBP OAGBP STD GBP
Av Initial weight loss 1-3yrs gt77 gt77 65-70
Weight loss 4-10 years 70-77 70-77 55-65
Resolution of T2DM 80--85 80-90 60-80
VomitingSolid Food Intolerance 5-15 lt5 lt5
Diarrhea and Steatorrhea 1-2A 15-30 NA
Symptomatic Reflux 1-3 3-11 1-3
Marginal Ulcers 3-5 3-5 3-5
Protein Caloric Malnutrition lt1 3-11 lt1
Significant Weight regain 3-10 3-10 10-35
Ringband Erosion 0-1 NA NA
CHOICE OF PROCEDURE
We have enough information currently to enhance the outcome and minimize the risk by matching the operation to the patient
That is the basis forAn Algorithm for Bariatric Metabolic Operations
CHOOSING THE BEST BARIATRIC METABOLIC PROCEDURE FOR THE PATIENT
CHOICE OF PROCEDURE
bull All agesbull With no diabetesbull With low BMI preferably lt40bull With no GERDbull With HO PUDbull With HO or findings of liver diseasebull With Inflammatory bowel diseasebull With dense adhesions from multiple small bowel surgeriesbull Without HO VTEbull In heavy smokers who are not likely to quitbull In gastric cancer endemic areasbull High Risk needing minimal anesthesia and OR timebull High BMI gt 60 as part of a two stage approach
ALGORITHM
LSG BSG
CHOICE OF PROCEDURE
Laparoscopic Sleeve Gastrectomy Or Banded Sleeve Gastrostomy (SGBSD) Indicated for Patients
-All ages-Patients with T2DM lt5years and HbA1-c lt8 C-Peptidegt2 and not on insulin
-Patients with GERD
-ALL BMI ----- -BGBPBMIlt50-- LGBP
Vegetarian (BGBP)
BGBPLGBP
CHOICE OF PROCEDURE
ALGORITHM
Laparoscopic Gastric Bypass(LGBP) or Banded Gastric Bypass(BGBP) Indicated for Patients
bull With Diabetes gt5 years HbA1cgt8 C-Peptide lt2andor on Insulinbull All agesbull All BMI particularly High BMI-gt50bull High risk patients with need for short anesthesia timebull Because it is an easy to perform procedurebull Best tolerated by non Vegetarian
bull GERD Is a contraindicationbull Liver disease is a contraindication
Must be able to follow up patient regularlyPatient must be able to afford the required supplements OAGB
CHOICE OF PROCEDURE
ALGORITHM
OAGBMGB for patients
Sleeve gastrectomy with duodenal bypass(SGDJB) in patients with indication for Gastric Bypass in Gastric Cancer Endemic Areas
As effective as GBPSame weight loss andmetabolic effects as gastric bypass
SG-DJB
CHOICE OF PROCEDURE
ALGORITHM
Sleeve gastrectomy with duodenal bypass(SGDJB) in patients
1Second stage operation for the sleeve gastrectomy
2 Non responders or complications of sleeve gastric bypass or OAGBMGB
BPD-DS SADI SASI SG with enteral bypass
CHOICE OF PROCEDURE
ALGORITHM
BPD-DS SADI SAGI SASI) Indicated for
Areas with high incidence of anemia and very strict vegetarian food habits
CHOICE OF PROCEDURE
ALGORITHM
Sleeve Gastrectomy with gastro-jejunal gastro-ileal or entero-enteral anastomosis
Intra Gastric Balloon ENDOBARRIER
V-BLOC Aspire AssistEndoscopic Plication
For a patient who does not want an intra abdominal gastro-intestinal procedure
CHOICE OF PROCEDURE
Should You Do A Bariatric Metabolic Operation Because That Is What The Patient Wantsrdquo
NOYESmdashIt depends HoweverA bariatric metabolic surgeon should be able to offer the best operation for the patient based on the patientrsquos profile It is good practice to refer the patient to a tertiary center if the surgeon does not offer the operation that meets the patients indication
CHOICE OF PROCEDURE
CHOOSING THE BEST BARIATRIC METABOLIC PROCEDURE FOR THE PATIENT
CHOICE OF PROCEDURE
Case 157 yo Male BMI 57KgM2 T2DM GERD Strict Vegetarian
Algorithm
Gastric bypass-----Preferably Banded gastric bypassmdash------GERD Vegetarian
Not Sleeve because of T2DM GERD and High BMI
Not OAGBMGB because of GERD and probable of protein deficiency
CHOOSING THE BEST BARIATRIC METABOLIC PROCEDURE FOR THE PATIENT
CHOICE OF PROCEDURE
Case 1128 y0 F BMI 42 PCO DUB OSA and HO Migraine headaches
AlgorithmSleeve GastrectomymdashPreferably a Ring banded Sleeve gastrectomy
----No T2DM---No GERDNot Gastric bypass mdash anemia smelly flatus
Not OAGBMGB----Anemia Foul smelling flatus and body odor----Protein deficiency
CHOOSING THE BEST BARIATRIC METABOLIC PROCEDURE FOR THE PATIENT
CHOICE OF PROCEDURE
Case 11137 yo Male BMI 68 OSA OA and a non vegetarian who works at your hospitalReferred by the pulmonologist at your medical Centre
Algorithm
OAGBMGBmdashHigh BMI Non Veg-better food tolerance patient very likely to be followedand to afford the supplements because of proximity to your center
Not sleeve---poor weight loss with sleeve in super obeseNot Banded sleeve---Good weight loss but poor food tolerance since patient is a non vegetarianNot Gastric bypass---Weight loss in super obese have high non response after gastric bypass
and the gastric bypass is technically a more difficult operation than the OAGBNot Banded gastric bypass ndashGood weight loss but a BGBP is a more difficult operation and
the patient will have some food intolerance because of the ring
SURGICAL TREATMENT OPTIONS
At Mohak we perform these standard three operations and their banded modifications
Sleeve Gastrectomy Gastric Bypass OAGBMGB
CHOICE OF PROCEDURE
Evidence based operations performed at MBRSC From 2010 t0 2017---Standardized OperationsLaparoscopic Sleeve Gastrectomybull 90-120 cc Sleevebull 2-5cm from pylorusbull Where a sleeve is indicated but a band is contraindicated or not affordableBanded Sleeve Gastrectomy (BSG) 84 EWL after 60 monthsbull 90-120 cc Sleevebull 2-5cm from pylorusbull Ring 65-75 cmbull At 3-6 cm below GE junctionBanded Gastric bypass (BGBP) 75 EWL 48 monthsbull Create 6mdash7cm long pouchbull 65-75 cm ring at 3-5 cm below GE junction and gt2cm above anastomosisbull Large Gastroenterostomy gt 2cm bull 100cm Roux Limb and 80 cm BP limb for BMIlt50bull 100cm Roux Limb and 150 cm BP limb for BMIgt50Mini-Gastric Bypass (MGB) (OAGB) 79 EWL 60 monthsbull 9-18cm long pouch ~25cm widebull BP Limb length of 180cm BMIlt50Banded Mini-Gastric Bypass(BMGB)(BOAGB)bull 9-18cm long pouch ~25cm widebull Ring 7-75 cmbull BP Limb length of 180cm BMI50
THE MOHAK PROTOCOLStandardized Bariatric and Robotic Surgery Operations
CHOICE OF PROCEDURE
Sleeve Gastrectomy (LSG) or Banded Sleeve Gastrectomy (BSG)bull Non-diabeticsbull No hiatal hernia or GERDbull HO Smokingbull HO alcohol usebull HO PUDbull Abnormal LFTs NASH and early Cirrhosisbull Pts from areas with high incidence of gastric cancer of H pylori infectionbull High risks patients and super obese patients as part of a two-staged operation
Gastric Bypass (LGBP) or Banded Gastric Bypass (BGBP) or Hybrid BGBPMGBbull Have T2DM with HgbA1c lt 8 and duration lt 5 yearsbull Have Hiatal hernia or GERDbull Are Vegetarianbull No nicotine addiction (smoking)bull Have HO Alcohol intake bull Have NASH at surgery-No cirrhosisbull Not likely to come back for follow up andbull Revision operation of Failed Sleeve gastrectomy GBP or MGB
MOHAK ALGORITHM
CHOICE OF PROCEDURE
One Anastomosis Gastric Bypass-Mini-Gastric Bypass (OAGBP-MGB) bull Have T2DM with HgbA1c 8 and durationgt5 yearsbull Have No GERDbull Are Non-vegetarianbull Have poor dentitionbull Most likely to return for follow up at the clinicbull No HO alcohol intakebull No Nicotine addiction (smoking)bull Normal LFTsbull No NASH at surgery or cirrhosisbull Commitment by our program to have 100 follow up of theses patient
Revision Operationbull Sleeve to Banded RY with 100 cm Al limb and 180 cm BP Limbbull MGB to diverted MGB for Reflux Existing BPL and 100cm ALbull MGB to GBP for PCM or reversal to normal anatomy for PCMmdashinterim gastrostomy feedingbull GBP to BGBP with 180cm BP limb for Weight regain or inadequate weight loss BMIlt40bull GBP to BGBP with 300cm common limb for Weight regain or inadequate weight loss BMIgt40
MOHAK ALGORITHM
CHOICE OF PROCEDURE
bull Laparoscopic Gastric Bypass
bull Laparoscopic Sleeve Gastrectomy
bull Divided Mini-Gastric Bypass
bull Biliopancreatic Diversion with DS
bull Single Anastomosis Duodeno-ileostomy
bull Gastric Plication
bull Banded Gastric Plication
bull Endoscopic Gastroplasty
bull Laparoscopic Adjustable Gastric bands
bull Balloon Implantation
bull Ileal interposition
These other operations will be used selectively based on patients needs and the surgeons determination
CHOICE OF PROCEDURE
The MOHAK Guide for Choice of Bariatric Metabolic Surgery Operations
Single Incision Laparoscopic Robotic and Endoscopic approaches are
available at patientsrsquo requests and the discretion of the surgeon
CHOICE OF PROCEDURE
The MOHAK Guide for Choice of Bariatric Metabolic Surgery Operations
Mohak Bariatrics and Robotics Surgery Center Motto
ldquoThe best operation for the patient by a competent surgeon in a well equipped hospital to maximize outcomes with the least amount of risks exposurerdquo
WE ARE ABLE TO CHOOSE THE BEST BARIATRIC METABOLIC PROCEDURE FOR YOUR PATIENT
Good long-term results are our marketing toolSuccessful patients make a lot of referralsbull
CHOICE OF PROCEDURE
The MOHAK Guide for Choice of Bariatric Metabolic Surgery Operations
We offer various treatment modalities for obesity The operation is
determined by the profile of the patient and guided by findings from
analysis of the data from our prospectively maintained database
MOHAK TEAM INDORE INDIA
THANK YOU
DISCLOSURESFounding President of Bariatec
Corporation that produces the
MSRtrade and GaBP Ringtrade devices
I had the Ring Banded
Gastric Bypass April 8 2011
to control Type 2 diabetes
Complete remission of
Diabetes with Loss and
maintenance of 58 lbs for
seven years
BMI 314 ----242
Hb A-1c 94---64
Blood glucose lt100
Sleep Apnea- resolved
Arthritis-resolved
Increased energy level
CHOICE OF PROCEDURE
RYGB MGBOAGB LSG
2671 3599 2775
LGB 1720
BGB 454
RobGB 346
SILGB 151
MGB 2671BMGB 134
RobMGB 595
SILMGB 199
LSG 1907
BSG 224
RobSG 130
SILS 514
CHOICE OF PROCEDURE
CASE MIX DISCLOSURE
CHOICE OF PROCEDURE
lsquoThose who cannot learn from the past
are condemned to repeat itrsquo
George Santayana
History doesnt repeat itself
but it does rhymerdquo
Mark Twain
CHOICE OF PROCEDURE
Obesity is a multifactorialmultisystem and life longdisease with medicalpsychological physicaleconomic and socialramifications
Any Treatment at bestprovides remission andamelioration not a cure
Choice of Operation
PharmacotherapyDietingPhysical exerciseBehavioral modificationPsychotherapySurgical intervention
Treatment Options
Choice of Operation
PharmacotherapyDietingPhysical exerciseBehavioral modificationPsychotherapy
Treatment Options
Without surgery these options individually or in combination result in a high recidivism rate
CHOICE OF PROCEDURE
PharmacotherapyDietingPhysical exerciseBehavioral modificationPsychotherapySurgical intervention
A multidisciplinary approach including Surgical intervention provides the only long term option for treatment of obesity
TREATMENT OPTIONS
CHOICE OF PROCEDURE
ARMAMENTARIUM OF BARIATRIC METABOLIC PROCEDURES
bull The least effective current surgical
operation is many fold more effective
than any known non surgical treatment
SOS
Study
What we have learnt thus far
CHOICE OF PROCEDURE
CHOICE OF PROCEDURE
WHAT WE HAVE LEARNT THUS FAR
No one operation fits the needs of all patients
Choice of Operation
1 We currently have a better understanding of the Disease entity Obesity and the determining factors that affect the treatment of obesity
2 Mechanisms of action of various bariatric metabolic operations
AND
3 We know more about the operations---the relative contra-indications and the short and long-term outcomes of the various procedures
CHOICE OF PROCEDURE
THE DISEASE OBESITY
CHOICE OF PROCEDURE
THE DISEASE OBESITY
Obesity is a multi-system disease
Determining factors in the obese that affect the outcome of operations
Co morbid conditions
Risk factors in surgical treatment of obesity
CHOICE OF PROCEDURE
DETERMINING FACTORS
Genetics Expression of ObesityResponse to surgical treatment
Medical Metabolic syndrome T2DM CAD HO VTE Presence or absence of GERD Liver status and Mental Illness
Patient profile BMI Age GenderSocio-psycho-economic Factors
Smoking Alcohol intake Access to post op care Distance from care provider Cost of the operation-Cost and availability of equipment devices and suppliesAffordability of post operative care-Supplements-educational-financial status
DemographicEnvironmental factorsVegetarianAreas endemic to certain problemsmdashCancer UlcersCultural norms
MECHANISMS OF ACTION OF VARIOUS BARIATRIC METABOLIC OPERATIONS
bull Restrictive Effect Control the reservoir size
bull Neural Stimulation of G-E full sense effectsatiation
bull Patient Compliance Forced behavior modification Motivation fear dyspepsia physical activity dietary habit alteration support group participation and physician contact
bull Malabsorptive Effect Bypassed segment of the GI tract results in mal absorption
bull Dumping Effect High caloric fluid and fatty food intolerance
bull Ghrelin Effect Anorexia
bull Foregut effect GIP PYY and Leptin effects
bull Hindgut effect GLP-I motilityNauseasatiation
bull Microbiota effect alteration of the bacterial flora of the gut alters absorption
bull Bile salts
CHOICE OF PROCEDURE
Currently known mechanisms responsible for the effects of the various bariatric metabolic operations include but not limited to
Outcomes of the various operationsWeight Loss and maintenanceResolution of co-morbid conditions---Contra-indications to the various operations--Complications inherent in the operations----
CHOICE OF PROCEDURE
bull Refluxbull Ulcersbull Nutrient deficienciesbull Protein caloric malnutritionbull DiarrheaSteatorrheabull Food Intolerancebull RingBand Migration
The Operations and Procedures
SURGICAL TREATMENT OPTIONS
A Bariatric Metabolic Surgeon should be able to Perform these three basic procedures and their modifications
Sleeve Gastrectomy Gastric Bypass OAGBMGB
CHOICE OF PROCEDURE
CHOICE OF PROCEDURE
Sleeve Gastrectomy Ring BandedSleeve Gastrectomy
The Ring Stabilizes The Size of The Sleeveand minimizes the disadvantagesSEEVE GASTRECTOMY
1 Relatively simple operation2 No disruption of gastrointestinal tract3 No gastro-intestinal anastomosis4 Nearly regular intestinal absorption 5 Low incidence of dumping syndrome6 0 risk of developing an internal hernia 7 Good weight loss and resolution of
co-morbid conditions almost equal to GBP
Disadvantages-Weight loss ltLGBP-Dilation of sleeve with weight regain and recurrence of co-morbid conditions
-Neo-reflux-Intractable leaks-Torsionstenosis-Porto-mesenteric thrombosis
CHOICE OF PROCEDURE
Sleeve Gastrectomy
Ring BandedSleeve Gastrectomy
06M 1 yr 2yr 3yr 4yr 5yr 6yr
EB
WL
Follow UP
p vs Baseline always lt0001 BSG LSG
Bhandari M Mathur W etal In Print SOARD
CHOICE OF PROCEDURE
THREE YEARS SIX YEARS
THREE YEARS SIX YEARSLess than 50 50-75 above75 Less than 50 50-75 above75
BSG (0) 0 (2) 35 (56) 965 (0) 0 (4) 83 (44) 917
LSG (15)111 (66)474 (53)395 (46)469 (46)469 (9)91
0102030405060708090
100
BSG
LSG
3 YEARSLSG 111BSG 0
FAILURE RATE
6 YEARSLSG 469BSG 0
CHOICE OF PROCEDURE
CHOICE OF PROCEDURE
Bhandari M Mathur W Mishra A MBRSC Course May 2017 Indore India
The Gastric Bypass is the Gold Standard of Bariatric Metabolic Operations
RGBP BGBP
CHOICE OF PROCEDURE
COMPARISON OF BGBP VS STD GBP
Outcome after the operations BGBP STD GBP
Av Initial weight loss 1-3yrs gt77 65-70
Weight loss 4-10 years 70-77 55-65
Resolution of T2DM 80--85 60-80
VomitingSolid Food Intolerance 5-15 lt5
Significant Weight regain 3-7 10-35
Ringband Erosion 0-2 NA
CHOICE OF PROCEDURE
OAGBPMGB
One Anastamosis Gastric BypassMini Gastric Bypass (OAGBMGB)
Simplicity
Repeatability
Minimal Dissection
Reversibility
Exit Strategy
Safety
Minimal Suturing
Short Duration
Short Learning Curve
CHOICE OF PROCEDURE
OAGBSAGBMGB Advantagesbull Easier operation compared to Standard GBPbull Better food tolerancebull More weight loss than standard GBPbull Better weigh Loss Maintenancebull Higher metabolic effect on T2DM and Hyperlipidemiabull Less incidence of internal herniabull More options for revision if needed
Disadvantagesbull Bile reflux gastritis and esophagitisbull Marginal ulcersbull Nutrient deficienciesbull Protein Caloric Malnutrition
Quan Y Huanh A Ye M Efficacy of laproscopic mini gastric bypass for obesity and type 2 diabetes mellitus A systematic review and met-analysis Gastroenterol Res Pract 2015 ID 152852 10155
CHOICE OF PROCEDURE
2015 ndash Review articleVictorzon M et al Scand J Surg 2015 Mar104(1)48-53 Single-anastomosis gastric
bypass better faster and safer
bull The abstracts of 73 articles were reviewed and after removal of case studies duplicates and irrelevant articles 10 articles remained for closer review
bull Several thousand of this operation have been performed for more than 15 years It is claimed to be an easier safer faster and more effective metabolic operation compared to the standard Roux-en-Y gastric bypass The proponents of this operation also claim that this operation is easier to revise and reverse leaving more options compared to the situation after standard bypass in case of failure However there is much controversy surrounding this method mainly concerning the possible harmful and in the long-term even carcinogenic effects of biliopancreaticoduodenal reflux in the gastric pouch
Comment
Several thousands MGBs performed over 15 yrsEasier safer faster amp more effective than
RYGBEasier to revise amp reverse
Controversy regarding carcinogenic effect of BPD reflux
1306
1213
1294
1218
131
1207
114
116
118
12
122
124
126
128
13
132
Before After
BGB LGB MGB
Hemoglobin
RYGB VS Banded RYGB VS OAGBMGB
CHOICE OF PROCEDURE
399
372
394
36
396
352
32
33
34
35
36
37
38
39
4
41
Before After
BGB LGB MGB
Albumin661
644
693
67
685
607
56
58
6
62
64
66
68
7
Before After
BGB LGB MGB
Protein
RYGB VS Banded RYGB VS OAGBMGB
CHOICE OF PROCEDURE
911
87
906
873
909
833
78
8
82
84
86
88
9
92
Before After
BGB LGB MGB
Calcium
CHOICE OF PROCEDURE
RYGB VS Banded RYGB VS OAGBMGB
COMPARISON OF BGBP OAGB VS STD GBP
Outcome after the operations BGBP OAGBP STD GBP
Av Initial weight loss 1-3yrs gt77 gt77 65-70
Weight loss 4-10 years 70-77 70-77 55-65
Resolution of T2DM 80--85 80-90 60-80
VomitingSolid Food Intolerance 5-15 lt5 lt5
Diarrhea and Steatorrhea 1-2A 15-30 NA
Symptomatic Reflux 1-3 3-11 1-3
Marginal Ulcers 3-5 3-5 3-5
Protein Caloric Malnutrition lt1 3-11 lt1
Significant Weight regain 3-10 3-10 10-35
Ringband Erosion 0-1 NA NA
CHOICE OF PROCEDURE
We have enough information currently to enhance the outcome and minimize the risk by matching the operation to the patient
That is the basis forAn Algorithm for Bariatric Metabolic Operations
CHOOSING THE BEST BARIATRIC METABOLIC PROCEDURE FOR THE PATIENT
CHOICE OF PROCEDURE
bull All agesbull With no diabetesbull With low BMI preferably lt40bull With no GERDbull With HO PUDbull With HO or findings of liver diseasebull With Inflammatory bowel diseasebull With dense adhesions from multiple small bowel surgeriesbull Without HO VTEbull In heavy smokers who are not likely to quitbull In gastric cancer endemic areasbull High Risk needing minimal anesthesia and OR timebull High BMI gt 60 as part of a two stage approach
ALGORITHM
LSG BSG
CHOICE OF PROCEDURE
Laparoscopic Sleeve Gastrectomy Or Banded Sleeve Gastrostomy (SGBSD) Indicated for Patients
-All ages-Patients with T2DM lt5years and HbA1-c lt8 C-Peptidegt2 and not on insulin
-Patients with GERD
-ALL BMI ----- -BGBPBMIlt50-- LGBP
Vegetarian (BGBP)
BGBPLGBP
CHOICE OF PROCEDURE
ALGORITHM
Laparoscopic Gastric Bypass(LGBP) or Banded Gastric Bypass(BGBP) Indicated for Patients
bull With Diabetes gt5 years HbA1cgt8 C-Peptide lt2andor on Insulinbull All agesbull All BMI particularly High BMI-gt50bull High risk patients with need for short anesthesia timebull Because it is an easy to perform procedurebull Best tolerated by non Vegetarian
bull GERD Is a contraindicationbull Liver disease is a contraindication
Must be able to follow up patient regularlyPatient must be able to afford the required supplements OAGB
CHOICE OF PROCEDURE
ALGORITHM
OAGBMGB for patients
Sleeve gastrectomy with duodenal bypass(SGDJB) in patients with indication for Gastric Bypass in Gastric Cancer Endemic Areas
As effective as GBPSame weight loss andmetabolic effects as gastric bypass
SG-DJB
CHOICE OF PROCEDURE
ALGORITHM
Sleeve gastrectomy with duodenal bypass(SGDJB) in patients
1Second stage operation for the sleeve gastrectomy
2 Non responders or complications of sleeve gastric bypass or OAGBMGB
BPD-DS SADI SASI SG with enteral bypass
CHOICE OF PROCEDURE
ALGORITHM
BPD-DS SADI SAGI SASI) Indicated for
Areas with high incidence of anemia and very strict vegetarian food habits
CHOICE OF PROCEDURE
ALGORITHM
Sleeve Gastrectomy with gastro-jejunal gastro-ileal or entero-enteral anastomosis
Intra Gastric Balloon ENDOBARRIER
V-BLOC Aspire AssistEndoscopic Plication
For a patient who does not want an intra abdominal gastro-intestinal procedure
CHOICE OF PROCEDURE
Should You Do A Bariatric Metabolic Operation Because That Is What The Patient Wantsrdquo
NOYESmdashIt depends HoweverA bariatric metabolic surgeon should be able to offer the best operation for the patient based on the patientrsquos profile It is good practice to refer the patient to a tertiary center if the surgeon does not offer the operation that meets the patients indication
CHOICE OF PROCEDURE
CHOOSING THE BEST BARIATRIC METABOLIC PROCEDURE FOR THE PATIENT
CHOICE OF PROCEDURE
Case 157 yo Male BMI 57KgM2 T2DM GERD Strict Vegetarian
Algorithm
Gastric bypass-----Preferably Banded gastric bypassmdash------GERD Vegetarian
Not Sleeve because of T2DM GERD and High BMI
Not OAGBMGB because of GERD and probable of protein deficiency
CHOOSING THE BEST BARIATRIC METABOLIC PROCEDURE FOR THE PATIENT
CHOICE OF PROCEDURE
Case 1128 y0 F BMI 42 PCO DUB OSA and HO Migraine headaches
AlgorithmSleeve GastrectomymdashPreferably a Ring banded Sleeve gastrectomy
----No T2DM---No GERDNot Gastric bypass mdash anemia smelly flatus
Not OAGBMGB----Anemia Foul smelling flatus and body odor----Protein deficiency
CHOOSING THE BEST BARIATRIC METABOLIC PROCEDURE FOR THE PATIENT
CHOICE OF PROCEDURE
Case 11137 yo Male BMI 68 OSA OA and a non vegetarian who works at your hospitalReferred by the pulmonologist at your medical Centre
Algorithm
OAGBMGBmdashHigh BMI Non Veg-better food tolerance patient very likely to be followedand to afford the supplements because of proximity to your center
Not sleeve---poor weight loss with sleeve in super obeseNot Banded sleeve---Good weight loss but poor food tolerance since patient is a non vegetarianNot Gastric bypass---Weight loss in super obese have high non response after gastric bypass
and the gastric bypass is technically a more difficult operation than the OAGBNot Banded gastric bypass ndashGood weight loss but a BGBP is a more difficult operation and
the patient will have some food intolerance because of the ring
SURGICAL TREATMENT OPTIONS
At Mohak we perform these standard three operations and their banded modifications
Sleeve Gastrectomy Gastric Bypass OAGBMGB
CHOICE OF PROCEDURE
Evidence based operations performed at MBRSC From 2010 t0 2017---Standardized OperationsLaparoscopic Sleeve Gastrectomybull 90-120 cc Sleevebull 2-5cm from pylorusbull Where a sleeve is indicated but a band is contraindicated or not affordableBanded Sleeve Gastrectomy (BSG) 84 EWL after 60 monthsbull 90-120 cc Sleevebull 2-5cm from pylorusbull Ring 65-75 cmbull At 3-6 cm below GE junctionBanded Gastric bypass (BGBP) 75 EWL 48 monthsbull Create 6mdash7cm long pouchbull 65-75 cm ring at 3-5 cm below GE junction and gt2cm above anastomosisbull Large Gastroenterostomy gt 2cm bull 100cm Roux Limb and 80 cm BP limb for BMIlt50bull 100cm Roux Limb and 150 cm BP limb for BMIgt50Mini-Gastric Bypass (MGB) (OAGB) 79 EWL 60 monthsbull 9-18cm long pouch ~25cm widebull BP Limb length of 180cm BMIlt50Banded Mini-Gastric Bypass(BMGB)(BOAGB)bull 9-18cm long pouch ~25cm widebull Ring 7-75 cmbull BP Limb length of 180cm BMI50
THE MOHAK PROTOCOLStandardized Bariatric and Robotic Surgery Operations
CHOICE OF PROCEDURE
Sleeve Gastrectomy (LSG) or Banded Sleeve Gastrectomy (BSG)bull Non-diabeticsbull No hiatal hernia or GERDbull HO Smokingbull HO alcohol usebull HO PUDbull Abnormal LFTs NASH and early Cirrhosisbull Pts from areas with high incidence of gastric cancer of H pylori infectionbull High risks patients and super obese patients as part of a two-staged operation
Gastric Bypass (LGBP) or Banded Gastric Bypass (BGBP) or Hybrid BGBPMGBbull Have T2DM with HgbA1c lt 8 and duration lt 5 yearsbull Have Hiatal hernia or GERDbull Are Vegetarianbull No nicotine addiction (smoking)bull Have HO Alcohol intake bull Have NASH at surgery-No cirrhosisbull Not likely to come back for follow up andbull Revision operation of Failed Sleeve gastrectomy GBP or MGB
MOHAK ALGORITHM
CHOICE OF PROCEDURE
One Anastomosis Gastric Bypass-Mini-Gastric Bypass (OAGBP-MGB) bull Have T2DM with HgbA1c 8 and durationgt5 yearsbull Have No GERDbull Are Non-vegetarianbull Have poor dentitionbull Most likely to return for follow up at the clinicbull No HO alcohol intakebull No Nicotine addiction (smoking)bull Normal LFTsbull No NASH at surgery or cirrhosisbull Commitment by our program to have 100 follow up of theses patient
Revision Operationbull Sleeve to Banded RY with 100 cm Al limb and 180 cm BP Limbbull MGB to diverted MGB for Reflux Existing BPL and 100cm ALbull MGB to GBP for PCM or reversal to normal anatomy for PCMmdashinterim gastrostomy feedingbull GBP to BGBP with 180cm BP limb for Weight regain or inadequate weight loss BMIlt40bull GBP to BGBP with 300cm common limb for Weight regain or inadequate weight loss BMIgt40
MOHAK ALGORITHM
CHOICE OF PROCEDURE
bull Laparoscopic Gastric Bypass
bull Laparoscopic Sleeve Gastrectomy
bull Divided Mini-Gastric Bypass
bull Biliopancreatic Diversion with DS
bull Single Anastomosis Duodeno-ileostomy
bull Gastric Plication
bull Banded Gastric Plication
bull Endoscopic Gastroplasty
bull Laparoscopic Adjustable Gastric bands
bull Balloon Implantation
bull Ileal interposition
These other operations will be used selectively based on patients needs and the surgeons determination
CHOICE OF PROCEDURE
The MOHAK Guide for Choice of Bariatric Metabolic Surgery Operations
Single Incision Laparoscopic Robotic and Endoscopic approaches are
available at patientsrsquo requests and the discretion of the surgeon
CHOICE OF PROCEDURE
The MOHAK Guide for Choice of Bariatric Metabolic Surgery Operations
Mohak Bariatrics and Robotics Surgery Center Motto
ldquoThe best operation for the patient by a competent surgeon in a well equipped hospital to maximize outcomes with the least amount of risks exposurerdquo
WE ARE ABLE TO CHOOSE THE BEST BARIATRIC METABOLIC PROCEDURE FOR YOUR PATIENT
Good long-term results are our marketing toolSuccessful patients make a lot of referralsbull
CHOICE OF PROCEDURE
The MOHAK Guide for Choice of Bariatric Metabolic Surgery Operations
We offer various treatment modalities for obesity The operation is
determined by the profile of the patient and guided by findings from
analysis of the data from our prospectively maintained database
MOHAK TEAM INDORE INDIA
THANK YOU
RYGB MGBOAGB LSG
2671 3599 2775
LGB 1720
BGB 454
RobGB 346
SILGB 151
MGB 2671BMGB 134
RobMGB 595
SILMGB 199
LSG 1907
BSG 224
RobSG 130
SILS 514
CHOICE OF PROCEDURE
CASE MIX DISCLOSURE
CHOICE OF PROCEDURE
lsquoThose who cannot learn from the past
are condemned to repeat itrsquo
George Santayana
History doesnt repeat itself
but it does rhymerdquo
Mark Twain
CHOICE OF PROCEDURE
Obesity is a multifactorialmultisystem and life longdisease with medicalpsychological physicaleconomic and socialramifications
Any Treatment at bestprovides remission andamelioration not a cure
Choice of Operation
PharmacotherapyDietingPhysical exerciseBehavioral modificationPsychotherapySurgical intervention
Treatment Options
Choice of Operation
PharmacotherapyDietingPhysical exerciseBehavioral modificationPsychotherapy
Treatment Options
Without surgery these options individually or in combination result in a high recidivism rate
CHOICE OF PROCEDURE
PharmacotherapyDietingPhysical exerciseBehavioral modificationPsychotherapySurgical intervention
A multidisciplinary approach including Surgical intervention provides the only long term option for treatment of obesity
TREATMENT OPTIONS
CHOICE OF PROCEDURE
ARMAMENTARIUM OF BARIATRIC METABOLIC PROCEDURES
bull The least effective current surgical
operation is many fold more effective
than any known non surgical treatment
SOS
Study
What we have learnt thus far
CHOICE OF PROCEDURE
CHOICE OF PROCEDURE
WHAT WE HAVE LEARNT THUS FAR
No one operation fits the needs of all patients
Choice of Operation
1 We currently have a better understanding of the Disease entity Obesity and the determining factors that affect the treatment of obesity
2 Mechanisms of action of various bariatric metabolic operations
AND
3 We know more about the operations---the relative contra-indications and the short and long-term outcomes of the various procedures
CHOICE OF PROCEDURE
THE DISEASE OBESITY
CHOICE OF PROCEDURE
THE DISEASE OBESITY
Obesity is a multi-system disease
Determining factors in the obese that affect the outcome of operations
Co morbid conditions
Risk factors in surgical treatment of obesity
CHOICE OF PROCEDURE
DETERMINING FACTORS
Genetics Expression of ObesityResponse to surgical treatment
Medical Metabolic syndrome T2DM CAD HO VTE Presence or absence of GERD Liver status and Mental Illness
Patient profile BMI Age GenderSocio-psycho-economic Factors
Smoking Alcohol intake Access to post op care Distance from care provider Cost of the operation-Cost and availability of equipment devices and suppliesAffordability of post operative care-Supplements-educational-financial status
DemographicEnvironmental factorsVegetarianAreas endemic to certain problemsmdashCancer UlcersCultural norms
MECHANISMS OF ACTION OF VARIOUS BARIATRIC METABOLIC OPERATIONS
bull Restrictive Effect Control the reservoir size
bull Neural Stimulation of G-E full sense effectsatiation
bull Patient Compliance Forced behavior modification Motivation fear dyspepsia physical activity dietary habit alteration support group participation and physician contact
bull Malabsorptive Effect Bypassed segment of the GI tract results in mal absorption
bull Dumping Effect High caloric fluid and fatty food intolerance
bull Ghrelin Effect Anorexia
bull Foregut effect GIP PYY and Leptin effects
bull Hindgut effect GLP-I motilityNauseasatiation
bull Microbiota effect alteration of the bacterial flora of the gut alters absorption
bull Bile salts
CHOICE OF PROCEDURE
Currently known mechanisms responsible for the effects of the various bariatric metabolic operations include but not limited to
Outcomes of the various operationsWeight Loss and maintenanceResolution of co-morbid conditions---Contra-indications to the various operations--Complications inherent in the operations----
CHOICE OF PROCEDURE
bull Refluxbull Ulcersbull Nutrient deficienciesbull Protein caloric malnutritionbull DiarrheaSteatorrheabull Food Intolerancebull RingBand Migration
The Operations and Procedures
SURGICAL TREATMENT OPTIONS
A Bariatric Metabolic Surgeon should be able to Perform these three basic procedures and their modifications
Sleeve Gastrectomy Gastric Bypass OAGBMGB
CHOICE OF PROCEDURE
CHOICE OF PROCEDURE
Sleeve Gastrectomy Ring BandedSleeve Gastrectomy
The Ring Stabilizes The Size of The Sleeveand minimizes the disadvantagesSEEVE GASTRECTOMY
1 Relatively simple operation2 No disruption of gastrointestinal tract3 No gastro-intestinal anastomosis4 Nearly regular intestinal absorption 5 Low incidence of dumping syndrome6 0 risk of developing an internal hernia 7 Good weight loss and resolution of
co-morbid conditions almost equal to GBP
Disadvantages-Weight loss ltLGBP-Dilation of sleeve with weight regain and recurrence of co-morbid conditions
-Neo-reflux-Intractable leaks-Torsionstenosis-Porto-mesenteric thrombosis
CHOICE OF PROCEDURE
Sleeve Gastrectomy
Ring BandedSleeve Gastrectomy
06M 1 yr 2yr 3yr 4yr 5yr 6yr
EB
WL
Follow UP
p vs Baseline always lt0001 BSG LSG
Bhandari M Mathur W etal In Print SOARD
CHOICE OF PROCEDURE
THREE YEARS SIX YEARS
THREE YEARS SIX YEARSLess than 50 50-75 above75 Less than 50 50-75 above75
BSG (0) 0 (2) 35 (56) 965 (0) 0 (4) 83 (44) 917
LSG (15)111 (66)474 (53)395 (46)469 (46)469 (9)91
0102030405060708090
100
BSG
LSG
3 YEARSLSG 111BSG 0
FAILURE RATE
6 YEARSLSG 469BSG 0
CHOICE OF PROCEDURE
CHOICE OF PROCEDURE
Bhandari M Mathur W Mishra A MBRSC Course May 2017 Indore India
The Gastric Bypass is the Gold Standard of Bariatric Metabolic Operations
RGBP BGBP
CHOICE OF PROCEDURE
COMPARISON OF BGBP VS STD GBP
Outcome after the operations BGBP STD GBP
Av Initial weight loss 1-3yrs gt77 65-70
Weight loss 4-10 years 70-77 55-65
Resolution of T2DM 80--85 60-80
VomitingSolid Food Intolerance 5-15 lt5
Significant Weight regain 3-7 10-35
Ringband Erosion 0-2 NA
CHOICE OF PROCEDURE
OAGBPMGB
One Anastamosis Gastric BypassMini Gastric Bypass (OAGBMGB)
Simplicity
Repeatability
Minimal Dissection
Reversibility
Exit Strategy
Safety
Minimal Suturing
Short Duration
Short Learning Curve
CHOICE OF PROCEDURE
OAGBSAGBMGB Advantagesbull Easier operation compared to Standard GBPbull Better food tolerancebull More weight loss than standard GBPbull Better weigh Loss Maintenancebull Higher metabolic effect on T2DM and Hyperlipidemiabull Less incidence of internal herniabull More options for revision if needed
Disadvantagesbull Bile reflux gastritis and esophagitisbull Marginal ulcersbull Nutrient deficienciesbull Protein Caloric Malnutrition
Quan Y Huanh A Ye M Efficacy of laproscopic mini gastric bypass for obesity and type 2 diabetes mellitus A systematic review and met-analysis Gastroenterol Res Pract 2015 ID 152852 10155
CHOICE OF PROCEDURE
2015 ndash Review articleVictorzon M et al Scand J Surg 2015 Mar104(1)48-53 Single-anastomosis gastric
bypass better faster and safer
bull The abstracts of 73 articles were reviewed and after removal of case studies duplicates and irrelevant articles 10 articles remained for closer review
bull Several thousand of this operation have been performed for more than 15 years It is claimed to be an easier safer faster and more effective metabolic operation compared to the standard Roux-en-Y gastric bypass The proponents of this operation also claim that this operation is easier to revise and reverse leaving more options compared to the situation after standard bypass in case of failure However there is much controversy surrounding this method mainly concerning the possible harmful and in the long-term even carcinogenic effects of biliopancreaticoduodenal reflux in the gastric pouch
Comment
Several thousands MGBs performed over 15 yrsEasier safer faster amp more effective than
RYGBEasier to revise amp reverse
Controversy regarding carcinogenic effect of BPD reflux
1306
1213
1294
1218
131
1207
114
116
118
12
122
124
126
128
13
132
Before After
BGB LGB MGB
Hemoglobin
RYGB VS Banded RYGB VS OAGBMGB
CHOICE OF PROCEDURE
399
372
394
36
396
352
32
33
34
35
36
37
38
39
4
41
Before After
BGB LGB MGB
Albumin661
644
693
67
685
607
56
58
6
62
64
66
68
7
Before After
BGB LGB MGB
Protein
RYGB VS Banded RYGB VS OAGBMGB
CHOICE OF PROCEDURE
911
87
906
873
909
833
78
8
82
84
86
88
9
92
Before After
BGB LGB MGB
Calcium
CHOICE OF PROCEDURE
RYGB VS Banded RYGB VS OAGBMGB
COMPARISON OF BGBP OAGB VS STD GBP
Outcome after the operations BGBP OAGBP STD GBP
Av Initial weight loss 1-3yrs gt77 gt77 65-70
Weight loss 4-10 years 70-77 70-77 55-65
Resolution of T2DM 80--85 80-90 60-80
VomitingSolid Food Intolerance 5-15 lt5 lt5
Diarrhea and Steatorrhea 1-2A 15-30 NA
Symptomatic Reflux 1-3 3-11 1-3
Marginal Ulcers 3-5 3-5 3-5
Protein Caloric Malnutrition lt1 3-11 lt1
Significant Weight regain 3-10 3-10 10-35
Ringband Erosion 0-1 NA NA
CHOICE OF PROCEDURE
We have enough information currently to enhance the outcome and minimize the risk by matching the operation to the patient
That is the basis forAn Algorithm for Bariatric Metabolic Operations
CHOOSING THE BEST BARIATRIC METABOLIC PROCEDURE FOR THE PATIENT
CHOICE OF PROCEDURE
bull All agesbull With no diabetesbull With low BMI preferably lt40bull With no GERDbull With HO PUDbull With HO or findings of liver diseasebull With Inflammatory bowel diseasebull With dense adhesions from multiple small bowel surgeriesbull Without HO VTEbull In heavy smokers who are not likely to quitbull In gastric cancer endemic areasbull High Risk needing minimal anesthesia and OR timebull High BMI gt 60 as part of a two stage approach
ALGORITHM
LSG BSG
CHOICE OF PROCEDURE
Laparoscopic Sleeve Gastrectomy Or Banded Sleeve Gastrostomy (SGBSD) Indicated for Patients
-All ages-Patients with T2DM lt5years and HbA1-c lt8 C-Peptidegt2 and not on insulin
-Patients with GERD
-ALL BMI ----- -BGBPBMIlt50-- LGBP
Vegetarian (BGBP)
BGBPLGBP
CHOICE OF PROCEDURE
ALGORITHM
Laparoscopic Gastric Bypass(LGBP) or Banded Gastric Bypass(BGBP) Indicated for Patients
bull With Diabetes gt5 years HbA1cgt8 C-Peptide lt2andor on Insulinbull All agesbull All BMI particularly High BMI-gt50bull High risk patients with need for short anesthesia timebull Because it is an easy to perform procedurebull Best tolerated by non Vegetarian
bull GERD Is a contraindicationbull Liver disease is a contraindication
Must be able to follow up patient regularlyPatient must be able to afford the required supplements OAGB
CHOICE OF PROCEDURE
ALGORITHM
OAGBMGB for patients
Sleeve gastrectomy with duodenal bypass(SGDJB) in patients with indication for Gastric Bypass in Gastric Cancer Endemic Areas
As effective as GBPSame weight loss andmetabolic effects as gastric bypass
SG-DJB
CHOICE OF PROCEDURE
ALGORITHM
Sleeve gastrectomy with duodenal bypass(SGDJB) in patients
1Second stage operation for the sleeve gastrectomy
2 Non responders or complications of sleeve gastric bypass or OAGBMGB
BPD-DS SADI SASI SG with enteral bypass
CHOICE OF PROCEDURE
ALGORITHM
BPD-DS SADI SAGI SASI) Indicated for
Areas with high incidence of anemia and very strict vegetarian food habits
CHOICE OF PROCEDURE
ALGORITHM
Sleeve Gastrectomy with gastro-jejunal gastro-ileal or entero-enteral anastomosis
Intra Gastric Balloon ENDOBARRIER
V-BLOC Aspire AssistEndoscopic Plication
For a patient who does not want an intra abdominal gastro-intestinal procedure
CHOICE OF PROCEDURE
Should You Do A Bariatric Metabolic Operation Because That Is What The Patient Wantsrdquo
NOYESmdashIt depends HoweverA bariatric metabolic surgeon should be able to offer the best operation for the patient based on the patientrsquos profile It is good practice to refer the patient to a tertiary center if the surgeon does not offer the operation that meets the patients indication
CHOICE OF PROCEDURE
CHOOSING THE BEST BARIATRIC METABOLIC PROCEDURE FOR THE PATIENT
CHOICE OF PROCEDURE
Case 157 yo Male BMI 57KgM2 T2DM GERD Strict Vegetarian
Algorithm
Gastric bypass-----Preferably Banded gastric bypassmdash------GERD Vegetarian
Not Sleeve because of T2DM GERD and High BMI
Not OAGBMGB because of GERD and probable of protein deficiency
CHOOSING THE BEST BARIATRIC METABOLIC PROCEDURE FOR THE PATIENT
CHOICE OF PROCEDURE
Case 1128 y0 F BMI 42 PCO DUB OSA and HO Migraine headaches
AlgorithmSleeve GastrectomymdashPreferably a Ring banded Sleeve gastrectomy
----No T2DM---No GERDNot Gastric bypass mdash anemia smelly flatus
Not OAGBMGB----Anemia Foul smelling flatus and body odor----Protein deficiency
CHOOSING THE BEST BARIATRIC METABOLIC PROCEDURE FOR THE PATIENT
CHOICE OF PROCEDURE
Case 11137 yo Male BMI 68 OSA OA and a non vegetarian who works at your hospitalReferred by the pulmonologist at your medical Centre
Algorithm
OAGBMGBmdashHigh BMI Non Veg-better food tolerance patient very likely to be followedand to afford the supplements because of proximity to your center
Not sleeve---poor weight loss with sleeve in super obeseNot Banded sleeve---Good weight loss but poor food tolerance since patient is a non vegetarianNot Gastric bypass---Weight loss in super obese have high non response after gastric bypass
and the gastric bypass is technically a more difficult operation than the OAGBNot Banded gastric bypass ndashGood weight loss but a BGBP is a more difficult operation and
the patient will have some food intolerance because of the ring
SURGICAL TREATMENT OPTIONS
At Mohak we perform these standard three operations and their banded modifications
Sleeve Gastrectomy Gastric Bypass OAGBMGB
CHOICE OF PROCEDURE
Evidence based operations performed at MBRSC From 2010 t0 2017---Standardized OperationsLaparoscopic Sleeve Gastrectomybull 90-120 cc Sleevebull 2-5cm from pylorusbull Where a sleeve is indicated but a band is contraindicated or not affordableBanded Sleeve Gastrectomy (BSG) 84 EWL after 60 monthsbull 90-120 cc Sleevebull 2-5cm from pylorusbull Ring 65-75 cmbull At 3-6 cm below GE junctionBanded Gastric bypass (BGBP) 75 EWL 48 monthsbull Create 6mdash7cm long pouchbull 65-75 cm ring at 3-5 cm below GE junction and gt2cm above anastomosisbull Large Gastroenterostomy gt 2cm bull 100cm Roux Limb and 80 cm BP limb for BMIlt50bull 100cm Roux Limb and 150 cm BP limb for BMIgt50Mini-Gastric Bypass (MGB) (OAGB) 79 EWL 60 monthsbull 9-18cm long pouch ~25cm widebull BP Limb length of 180cm BMIlt50Banded Mini-Gastric Bypass(BMGB)(BOAGB)bull 9-18cm long pouch ~25cm widebull Ring 7-75 cmbull BP Limb length of 180cm BMI50
THE MOHAK PROTOCOLStandardized Bariatric and Robotic Surgery Operations
CHOICE OF PROCEDURE
Sleeve Gastrectomy (LSG) or Banded Sleeve Gastrectomy (BSG)bull Non-diabeticsbull No hiatal hernia or GERDbull HO Smokingbull HO alcohol usebull HO PUDbull Abnormal LFTs NASH and early Cirrhosisbull Pts from areas with high incidence of gastric cancer of H pylori infectionbull High risks patients and super obese patients as part of a two-staged operation
Gastric Bypass (LGBP) or Banded Gastric Bypass (BGBP) or Hybrid BGBPMGBbull Have T2DM with HgbA1c lt 8 and duration lt 5 yearsbull Have Hiatal hernia or GERDbull Are Vegetarianbull No nicotine addiction (smoking)bull Have HO Alcohol intake bull Have NASH at surgery-No cirrhosisbull Not likely to come back for follow up andbull Revision operation of Failed Sleeve gastrectomy GBP or MGB
MOHAK ALGORITHM
CHOICE OF PROCEDURE
One Anastomosis Gastric Bypass-Mini-Gastric Bypass (OAGBP-MGB) bull Have T2DM with HgbA1c 8 and durationgt5 yearsbull Have No GERDbull Are Non-vegetarianbull Have poor dentitionbull Most likely to return for follow up at the clinicbull No HO alcohol intakebull No Nicotine addiction (smoking)bull Normal LFTsbull No NASH at surgery or cirrhosisbull Commitment by our program to have 100 follow up of theses patient
Revision Operationbull Sleeve to Banded RY with 100 cm Al limb and 180 cm BP Limbbull MGB to diverted MGB for Reflux Existing BPL and 100cm ALbull MGB to GBP for PCM or reversal to normal anatomy for PCMmdashinterim gastrostomy feedingbull GBP to BGBP with 180cm BP limb for Weight regain or inadequate weight loss BMIlt40bull GBP to BGBP with 300cm common limb for Weight regain or inadequate weight loss BMIgt40
MOHAK ALGORITHM
CHOICE OF PROCEDURE
bull Laparoscopic Gastric Bypass
bull Laparoscopic Sleeve Gastrectomy
bull Divided Mini-Gastric Bypass
bull Biliopancreatic Diversion with DS
bull Single Anastomosis Duodeno-ileostomy
bull Gastric Plication
bull Banded Gastric Plication
bull Endoscopic Gastroplasty
bull Laparoscopic Adjustable Gastric bands
bull Balloon Implantation
bull Ileal interposition
These other operations will be used selectively based on patients needs and the surgeons determination
CHOICE OF PROCEDURE
The MOHAK Guide for Choice of Bariatric Metabolic Surgery Operations
Single Incision Laparoscopic Robotic and Endoscopic approaches are
available at patientsrsquo requests and the discretion of the surgeon
CHOICE OF PROCEDURE
The MOHAK Guide for Choice of Bariatric Metabolic Surgery Operations
Mohak Bariatrics and Robotics Surgery Center Motto
ldquoThe best operation for the patient by a competent surgeon in a well equipped hospital to maximize outcomes with the least amount of risks exposurerdquo
WE ARE ABLE TO CHOOSE THE BEST BARIATRIC METABOLIC PROCEDURE FOR YOUR PATIENT
Good long-term results are our marketing toolSuccessful patients make a lot of referralsbull
CHOICE OF PROCEDURE
The MOHAK Guide for Choice of Bariatric Metabolic Surgery Operations
We offer various treatment modalities for obesity The operation is
determined by the profile of the patient and guided by findings from
analysis of the data from our prospectively maintained database
MOHAK TEAM INDORE INDIA
THANK YOU
CHOICE OF PROCEDURE
lsquoThose who cannot learn from the past
are condemned to repeat itrsquo
George Santayana
History doesnt repeat itself
but it does rhymerdquo
Mark Twain
CHOICE OF PROCEDURE
Obesity is a multifactorialmultisystem and life longdisease with medicalpsychological physicaleconomic and socialramifications
Any Treatment at bestprovides remission andamelioration not a cure
Choice of Operation
PharmacotherapyDietingPhysical exerciseBehavioral modificationPsychotherapySurgical intervention
Treatment Options
Choice of Operation
PharmacotherapyDietingPhysical exerciseBehavioral modificationPsychotherapy
Treatment Options
Without surgery these options individually or in combination result in a high recidivism rate
CHOICE OF PROCEDURE
PharmacotherapyDietingPhysical exerciseBehavioral modificationPsychotherapySurgical intervention
A multidisciplinary approach including Surgical intervention provides the only long term option for treatment of obesity
TREATMENT OPTIONS
CHOICE OF PROCEDURE
ARMAMENTARIUM OF BARIATRIC METABOLIC PROCEDURES
bull The least effective current surgical
operation is many fold more effective
than any known non surgical treatment
SOS
Study
What we have learnt thus far
CHOICE OF PROCEDURE
CHOICE OF PROCEDURE
WHAT WE HAVE LEARNT THUS FAR
No one operation fits the needs of all patients
Choice of Operation
1 We currently have a better understanding of the Disease entity Obesity and the determining factors that affect the treatment of obesity
2 Mechanisms of action of various bariatric metabolic operations
AND
3 We know more about the operations---the relative contra-indications and the short and long-term outcomes of the various procedures
CHOICE OF PROCEDURE
THE DISEASE OBESITY
CHOICE OF PROCEDURE
THE DISEASE OBESITY
Obesity is a multi-system disease
Determining factors in the obese that affect the outcome of operations
Co morbid conditions
Risk factors in surgical treatment of obesity
CHOICE OF PROCEDURE
DETERMINING FACTORS
Genetics Expression of ObesityResponse to surgical treatment
Medical Metabolic syndrome T2DM CAD HO VTE Presence or absence of GERD Liver status and Mental Illness
Patient profile BMI Age GenderSocio-psycho-economic Factors
Smoking Alcohol intake Access to post op care Distance from care provider Cost of the operation-Cost and availability of equipment devices and suppliesAffordability of post operative care-Supplements-educational-financial status
DemographicEnvironmental factorsVegetarianAreas endemic to certain problemsmdashCancer UlcersCultural norms
MECHANISMS OF ACTION OF VARIOUS BARIATRIC METABOLIC OPERATIONS
bull Restrictive Effect Control the reservoir size
bull Neural Stimulation of G-E full sense effectsatiation
bull Patient Compliance Forced behavior modification Motivation fear dyspepsia physical activity dietary habit alteration support group participation and physician contact
bull Malabsorptive Effect Bypassed segment of the GI tract results in mal absorption
bull Dumping Effect High caloric fluid and fatty food intolerance
bull Ghrelin Effect Anorexia
bull Foregut effect GIP PYY and Leptin effects
bull Hindgut effect GLP-I motilityNauseasatiation
bull Microbiota effect alteration of the bacterial flora of the gut alters absorption
bull Bile salts
CHOICE OF PROCEDURE
Currently known mechanisms responsible for the effects of the various bariatric metabolic operations include but not limited to
Outcomes of the various operationsWeight Loss and maintenanceResolution of co-morbid conditions---Contra-indications to the various operations--Complications inherent in the operations----
CHOICE OF PROCEDURE
bull Refluxbull Ulcersbull Nutrient deficienciesbull Protein caloric malnutritionbull DiarrheaSteatorrheabull Food Intolerancebull RingBand Migration
The Operations and Procedures
SURGICAL TREATMENT OPTIONS
A Bariatric Metabolic Surgeon should be able to Perform these three basic procedures and their modifications
Sleeve Gastrectomy Gastric Bypass OAGBMGB
CHOICE OF PROCEDURE
CHOICE OF PROCEDURE
Sleeve Gastrectomy Ring BandedSleeve Gastrectomy
The Ring Stabilizes The Size of The Sleeveand minimizes the disadvantagesSEEVE GASTRECTOMY
1 Relatively simple operation2 No disruption of gastrointestinal tract3 No gastro-intestinal anastomosis4 Nearly regular intestinal absorption 5 Low incidence of dumping syndrome6 0 risk of developing an internal hernia 7 Good weight loss and resolution of
co-morbid conditions almost equal to GBP
Disadvantages-Weight loss ltLGBP-Dilation of sleeve with weight regain and recurrence of co-morbid conditions
-Neo-reflux-Intractable leaks-Torsionstenosis-Porto-mesenteric thrombosis
CHOICE OF PROCEDURE
Sleeve Gastrectomy
Ring BandedSleeve Gastrectomy
06M 1 yr 2yr 3yr 4yr 5yr 6yr
EB
WL
Follow UP
p vs Baseline always lt0001 BSG LSG
Bhandari M Mathur W etal In Print SOARD
CHOICE OF PROCEDURE
THREE YEARS SIX YEARS
THREE YEARS SIX YEARSLess than 50 50-75 above75 Less than 50 50-75 above75
BSG (0) 0 (2) 35 (56) 965 (0) 0 (4) 83 (44) 917
LSG (15)111 (66)474 (53)395 (46)469 (46)469 (9)91
0102030405060708090
100
BSG
LSG
3 YEARSLSG 111BSG 0
FAILURE RATE
6 YEARSLSG 469BSG 0
CHOICE OF PROCEDURE
CHOICE OF PROCEDURE
Bhandari M Mathur W Mishra A MBRSC Course May 2017 Indore India
The Gastric Bypass is the Gold Standard of Bariatric Metabolic Operations
RGBP BGBP
CHOICE OF PROCEDURE
COMPARISON OF BGBP VS STD GBP
Outcome after the operations BGBP STD GBP
Av Initial weight loss 1-3yrs gt77 65-70
Weight loss 4-10 years 70-77 55-65
Resolution of T2DM 80--85 60-80
VomitingSolid Food Intolerance 5-15 lt5
Significant Weight regain 3-7 10-35
Ringband Erosion 0-2 NA
CHOICE OF PROCEDURE
OAGBPMGB
One Anastamosis Gastric BypassMini Gastric Bypass (OAGBMGB)
Simplicity
Repeatability
Minimal Dissection
Reversibility
Exit Strategy
Safety
Minimal Suturing
Short Duration
Short Learning Curve
CHOICE OF PROCEDURE
OAGBSAGBMGB Advantagesbull Easier operation compared to Standard GBPbull Better food tolerancebull More weight loss than standard GBPbull Better weigh Loss Maintenancebull Higher metabolic effect on T2DM and Hyperlipidemiabull Less incidence of internal herniabull More options for revision if needed
Disadvantagesbull Bile reflux gastritis and esophagitisbull Marginal ulcersbull Nutrient deficienciesbull Protein Caloric Malnutrition
Quan Y Huanh A Ye M Efficacy of laproscopic mini gastric bypass for obesity and type 2 diabetes mellitus A systematic review and met-analysis Gastroenterol Res Pract 2015 ID 152852 10155
CHOICE OF PROCEDURE
2015 ndash Review articleVictorzon M et al Scand J Surg 2015 Mar104(1)48-53 Single-anastomosis gastric
bypass better faster and safer
bull The abstracts of 73 articles were reviewed and after removal of case studies duplicates and irrelevant articles 10 articles remained for closer review
bull Several thousand of this operation have been performed for more than 15 years It is claimed to be an easier safer faster and more effective metabolic operation compared to the standard Roux-en-Y gastric bypass The proponents of this operation also claim that this operation is easier to revise and reverse leaving more options compared to the situation after standard bypass in case of failure However there is much controversy surrounding this method mainly concerning the possible harmful and in the long-term even carcinogenic effects of biliopancreaticoduodenal reflux in the gastric pouch
Comment
Several thousands MGBs performed over 15 yrsEasier safer faster amp more effective than
RYGBEasier to revise amp reverse
Controversy regarding carcinogenic effect of BPD reflux
1306
1213
1294
1218
131
1207
114
116
118
12
122
124
126
128
13
132
Before After
BGB LGB MGB
Hemoglobin
RYGB VS Banded RYGB VS OAGBMGB
CHOICE OF PROCEDURE
399
372
394
36
396
352
32
33
34
35
36
37
38
39
4
41
Before After
BGB LGB MGB
Albumin661
644
693
67
685
607
56
58
6
62
64
66
68
7
Before After
BGB LGB MGB
Protein
RYGB VS Banded RYGB VS OAGBMGB
CHOICE OF PROCEDURE
911
87
906
873
909
833
78
8
82
84
86
88
9
92
Before After
BGB LGB MGB
Calcium
CHOICE OF PROCEDURE
RYGB VS Banded RYGB VS OAGBMGB
COMPARISON OF BGBP OAGB VS STD GBP
Outcome after the operations BGBP OAGBP STD GBP
Av Initial weight loss 1-3yrs gt77 gt77 65-70
Weight loss 4-10 years 70-77 70-77 55-65
Resolution of T2DM 80--85 80-90 60-80
VomitingSolid Food Intolerance 5-15 lt5 lt5
Diarrhea and Steatorrhea 1-2A 15-30 NA
Symptomatic Reflux 1-3 3-11 1-3
Marginal Ulcers 3-5 3-5 3-5
Protein Caloric Malnutrition lt1 3-11 lt1
Significant Weight regain 3-10 3-10 10-35
Ringband Erosion 0-1 NA NA
CHOICE OF PROCEDURE
We have enough information currently to enhance the outcome and minimize the risk by matching the operation to the patient
That is the basis forAn Algorithm for Bariatric Metabolic Operations
CHOOSING THE BEST BARIATRIC METABOLIC PROCEDURE FOR THE PATIENT
CHOICE OF PROCEDURE
bull All agesbull With no diabetesbull With low BMI preferably lt40bull With no GERDbull With HO PUDbull With HO or findings of liver diseasebull With Inflammatory bowel diseasebull With dense adhesions from multiple small bowel surgeriesbull Without HO VTEbull In heavy smokers who are not likely to quitbull In gastric cancer endemic areasbull High Risk needing minimal anesthesia and OR timebull High BMI gt 60 as part of a two stage approach
ALGORITHM
LSG BSG
CHOICE OF PROCEDURE
Laparoscopic Sleeve Gastrectomy Or Banded Sleeve Gastrostomy (SGBSD) Indicated for Patients
-All ages-Patients with T2DM lt5years and HbA1-c lt8 C-Peptidegt2 and not on insulin
-Patients with GERD
-ALL BMI ----- -BGBPBMIlt50-- LGBP
Vegetarian (BGBP)
BGBPLGBP
CHOICE OF PROCEDURE
ALGORITHM
Laparoscopic Gastric Bypass(LGBP) or Banded Gastric Bypass(BGBP) Indicated for Patients
bull With Diabetes gt5 years HbA1cgt8 C-Peptide lt2andor on Insulinbull All agesbull All BMI particularly High BMI-gt50bull High risk patients with need for short anesthesia timebull Because it is an easy to perform procedurebull Best tolerated by non Vegetarian
bull GERD Is a contraindicationbull Liver disease is a contraindication
Must be able to follow up patient regularlyPatient must be able to afford the required supplements OAGB
CHOICE OF PROCEDURE
ALGORITHM
OAGBMGB for patients
Sleeve gastrectomy with duodenal bypass(SGDJB) in patients with indication for Gastric Bypass in Gastric Cancer Endemic Areas
As effective as GBPSame weight loss andmetabolic effects as gastric bypass
SG-DJB
CHOICE OF PROCEDURE
ALGORITHM
Sleeve gastrectomy with duodenal bypass(SGDJB) in patients
1Second stage operation for the sleeve gastrectomy
2 Non responders or complications of sleeve gastric bypass or OAGBMGB
BPD-DS SADI SASI SG with enteral bypass
CHOICE OF PROCEDURE
ALGORITHM
BPD-DS SADI SAGI SASI) Indicated for
Areas with high incidence of anemia and very strict vegetarian food habits
CHOICE OF PROCEDURE
ALGORITHM
Sleeve Gastrectomy with gastro-jejunal gastro-ileal or entero-enteral anastomosis
Intra Gastric Balloon ENDOBARRIER
V-BLOC Aspire AssistEndoscopic Plication
For a patient who does not want an intra abdominal gastro-intestinal procedure
CHOICE OF PROCEDURE
Should You Do A Bariatric Metabolic Operation Because That Is What The Patient Wantsrdquo
NOYESmdashIt depends HoweverA bariatric metabolic surgeon should be able to offer the best operation for the patient based on the patientrsquos profile It is good practice to refer the patient to a tertiary center if the surgeon does not offer the operation that meets the patients indication
CHOICE OF PROCEDURE
CHOOSING THE BEST BARIATRIC METABOLIC PROCEDURE FOR THE PATIENT
CHOICE OF PROCEDURE
Case 157 yo Male BMI 57KgM2 T2DM GERD Strict Vegetarian
Algorithm
Gastric bypass-----Preferably Banded gastric bypassmdash------GERD Vegetarian
Not Sleeve because of T2DM GERD and High BMI
Not OAGBMGB because of GERD and probable of protein deficiency
CHOOSING THE BEST BARIATRIC METABOLIC PROCEDURE FOR THE PATIENT
CHOICE OF PROCEDURE
Case 1128 y0 F BMI 42 PCO DUB OSA and HO Migraine headaches
AlgorithmSleeve GastrectomymdashPreferably a Ring banded Sleeve gastrectomy
----No T2DM---No GERDNot Gastric bypass mdash anemia smelly flatus
Not OAGBMGB----Anemia Foul smelling flatus and body odor----Protein deficiency
CHOOSING THE BEST BARIATRIC METABOLIC PROCEDURE FOR THE PATIENT
CHOICE OF PROCEDURE
Case 11137 yo Male BMI 68 OSA OA and a non vegetarian who works at your hospitalReferred by the pulmonologist at your medical Centre
Algorithm
OAGBMGBmdashHigh BMI Non Veg-better food tolerance patient very likely to be followedand to afford the supplements because of proximity to your center
Not sleeve---poor weight loss with sleeve in super obeseNot Banded sleeve---Good weight loss but poor food tolerance since patient is a non vegetarianNot Gastric bypass---Weight loss in super obese have high non response after gastric bypass
and the gastric bypass is technically a more difficult operation than the OAGBNot Banded gastric bypass ndashGood weight loss but a BGBP is a more difficult operation and
the patient will have some food intolerance because of the ring
SURGICAL TREATMENT OPTIONS
At Mohak we perform these standard three operations and their banded modifications
Sleeve Gastrectomy Gastric Bypass OAGBMGB
CHOICE OF PROCEDURE
Evidence based operations performed at MBRSC From 2010 t0 2017---Standardized OperationsLaparoscopic Sleeve Gastrectomybull 90-120 cc Sleevebull 2-5cm from pylorusbull Where a sleeve is indicated but a band is contraindicated or not affordableBanded Sleeve Gastrectomy (BSG) 84 EWL after 60 monthsbull 90-120 cc Sleevebull 2-5cm from pylorusbull Ring 65-75 cmbull At 3-6 cm below GE junctionBanded Gastric bypass (BGBP) 75 EWL 48 monthsbull Create 6mdash7cm long pouchbull 65-75 cm ring at 3-5 cm below GE junction and gt2cm above anastomosisbull Large Gastroenterostomy gt 2cm bull 100cm Roux Limb and 80 cm BP limb for BMIlt50bull 100cm Roux Limb and 150 cm BP limb for BMIgt50Mini-Gastric Bypass (MGB) (OAGB) 79 EWL 60 monthsbull 9-18cm long pouch ~25cm widebull BP Limb length of 180cm BMIlt50Banded Mini-Gastric Bypass(BMGB)(BOAGB)bull 9-18cm long pouch ~25cm widebull Ring 7-75 cmbull BP Limb length of 180cm BMI50
THE MOHAK PROTOCOLStandardized Bariatric and Robotic Surgery Operations
CHOICE OF PROCEDURE
Sleeve Gastrectomy (LSG) or Banded Sleeve Gastrectomy (BSG)bull Non-diabeticsbull No hiatal hernia or GERDbull HO Smokingbull HO alcohol usebull HO PUDbull Abnormal LFTs NASH and early Cirrhosisbull Pts from areas with high incidence of gastric cancer of H pylori infectionbull High risks patients and super obese patients as part of a two-staged operation
Gastric Bypass (LGBP) or Banded Gastric Bypass (BGBP) or Hybrid BGBPMGBbull Have T2DM with HgbA1c lt 8 and duration lt 5 yearsbull Have Hiatal hernia or GERDbull Are Vegetarianbull No nicotine addiction (smoking)bull Have HO Alcohol intake bull Have NASH at surgery-No cirrhosisbull Not likely to come back for follow up andbull Revision operation of Failed Sleeve gastrectomy GBP or MGB
MOHAK ALGORITHM
CHOICE OF PROCEDURE
One Anastomosis Gastric Bypass-Mini-Gastric Bypass (OAGBP-MGB) bull Have T2DM with HgbA1c 8 and durationgt5 yearsbull Have No GERDbull Are Non-vegetarianbull Have poor dentitionbull Most likely to return for follow up at the clinicbull No HO alcohol intakebull No Nicotine addiction (smoking)bull Normal LFTsbull No NASH at surgery or cirrhosisbull Commitment by our program to have 100 follow up of theses patient
Revision Operationbull Sleeve to Banded RY with 100 cm Al limb and 180 cm BP Limbbull MGB to diverted MGB for Reflux Existing BPL and 100cm ALbull MGB to GBP for PCM or reversal to normal anatomy for PCMmdashinterim gastrostomy feedingbull GBP to BGBP with 180cm BP limb for Weight regain or inadequate weight loss BMIlt40bull GBP to BGBP with 300cm common limb for Weight regain or inadequate weight loss BMIgt40
MOHAK ALGORITHM
CHOICE OF PROCEDURE
bull Laparoscopic Gastric Bypass
bull Laparoscopic Sleeve Gastrectomy
bull Divided Mini-Gastric Bypass
bull Biliopancreatic Diversion with DS
bull Single Anastomosis Duodeno-ileostomy
bull Gastric Plication
bull Banded Gastric Plication
bull Endoscopic Gastroplasty
bull Laparoscopic Adjustable Gastric bands
bull Balloon Implantation
bull Ileal interposition
These other operations will be used selectively based on patients needs and the surgeons determination
CHOICE OF PROCEDURE
The MOHAK Guide for Choice of Bariatric Metabolic Surgery Operations
Single Incision Laparoscopic Robotic and Endoscopic approaches are
available at patientsrsquo requests and the discretion of the surgeon
CHOICE OF PROCEDURE
The MOHAK Guide for Choice of Bariatric Metabolic Surgery Operations
Mohak Bariatrics and Robotics Surgery Center Motto
ldquoThe best operation for the patient by a competent surgeon in a well equipped hospital to maximize outcomes with the least amount of risks exposurerdquo
WE ARE ABLE TO CHOOSE THE BEST BARIATRIC METABOLIC PROCEDURE FOR YOUR PATIENT
Good long-term results are our marketing toolSuccessful patients make a lot of referralsbull
CHOICE OF PROCEDURE
The MOHAK Guide for Choice of Bariatric Metabolic Surgery Operations
We offer various treatment modalities for obesity The operation is
determined by the profile of the patient and guided by findings from
analysis of the data from our prospectively maintained database
MOHAK TEAM INDORE INDIA
THANK YOU
CHOICE OF PROCEDURE
Obesity is a multifactorialmultisystem and life longdisease with medicalpsychological physicaleconomic and socialramifications
Any Treatment at bestprovides remission andamelioration not a cure
Choice of Operation
PharmacotherapyDietingPhysical exerciseBehavioral modificationPsychotherapySurgical intervention
Treatment Options
Choice of Operation
PharmacotherapyDietingPhysical exerciseBehavioral modificationPsychotherapy
Treatment Options
Without surgery these options individually or in combination result in a high recidivism rate
CHOICE OF PROCEDURE
PharmacotherapyDietingPhysical exerciseBehavioral modificationPsychotherapySurgical intervention
A multidisciplinary approach including Surgical intervention provides the only long term option for treatment of obesity
TREATMENT OPTIONS
CHOICE OF PROCEDURE
ARMAMENTARIUM OF BARIATRIC METABOLIC PROCEDURES
bull The least effective current surgical
operation is many fold more effective
than any known non surgical treatment
SOS
Study
What we have learnt thus far
CHOICE OF PROCEDURE
CHOICE OF PROCEDURE
WHAT WE HAVE LEARNT THUS FAR
No one operation fits the needs of all patients
Choice of Operation
1 We currently have a better understanding of the Disease entity Obesity and the determining factors that affect the treatment of obesity
2 Mechanisms of action of various bariatric metabolic operations
AND
3 We know more about the operations---the relative contra-indications and the short and long-term outcomes of the various procedures
CHOICE OF PROCEDURE
THE DISEASE OBESITY
CHOICE OF PROCEDURE
THE DISEASE OBESITY
Obesity is a multi-system disease
Determining factors in the obese that affect the outcome of operations
Co morbid conditions
Risk factors in surgical treatment of obesity
CHOICE OF PROCEDURE
DETERMINING FACTORS
Genetics Expression of ObesityResponse to surgical treatment
Medical Metabolic syndrome T2DM CAD HO VTE Presence or absence of GERD Liver status and Mental Illness
Patient profile BMI Age GenderSocio-psycho-economic Factors
Smoking Alcohol intake Access to post op care Distance from care provider Cost of the operation-Cost and availability of equipment devices and suppliesAffordability of post operative care-Supplements-educational-financial status
DemographicEnvironmental factorsVegetarianAreas endemic to certain problemsmdashCancer UlcersCultural norms
MECHANISMS OF ACTION OF VARIOUS BARIATRIC METABOLIC OPERATIONS
bull Restrictive Effect Control the reservoir size
bull Neural Stimulation of G-E full sense effectsatiation
bull Patient Compliance Forced behavior modification Motivation fear dyspepsia physical activity dietary habit alteration support group participation and physician contact
bull Malabsorptive Effect Bypassed segment of the GI tract results in mal absorption
bull Dumping Effect High caloric fluid and fatty food intolerance
bull Ghrelin Effect Anorexia
bull Foregut effect GIP PYY and Leptin effects
bull Hindgut effect GLP-I motilityNauseasatiation
bull Microbiota effect alteration of the bacterial flora of the gut alters absorption
bull Bile salts
CHOICE OF PROCEDURE
Currently known mechanisms responsible for the effects of the various bariatric metabolic operations include but not limited to
Outcomes of the various operationsWeight Loss and maintenanceResolution of co-morbid conditions---Contra-indications to the various operations--Complications inherent in the operations----
CHOICE OF PROCEDURE
bull Refluxbull Ulcersbull Nutrient deficienciesbull Protein caloric malnutritionbull DiarrheaSteatorrheabull Food Intolerancebull RingBand Migration
The Operations and Procedures
SURGICAL TREATMENT OPTIONS
A Bariatric Metabolic Surgeon should be able to Perform these three basic procedures and their modifications
Sleeve Gastrectomy Gastric Bypass OAGBMGB
CHOICE OF PROCEDURE
CHOICE OF PROCEDURE
Sleeve Gastrectomy Ring BandedSleeve Gastrectomy
The Ring Stabilizes The Size of The Sleeveand minimizes the disadvantagesSEEVE GASTRECTOMY
1 Relatively simple operation2 No disruption of gastrointestinal tract3 No gastro-intestinal anastomosis4 Nearly regular intestinal absorption 5 Low incidence of dumping syndrome6 0 risk of developing an internal hernia 7 Good weight loss and resolution of
co-morbid conditions almost equal to GBP
Disadvantages-Weight loss ltLGBP-Dilation of sleeve with weight regain and recurrence of co-morbid conditions
-Neo-reflux-Intractable leaks-Torsionstenosis-Porto-mesenteric thrombosis
CHOICE OF PROCEDURE
Sleeve Gastrectomy
Ring BandedSleeve Gastrectomy
06M 1 yr 2yr 3yr 4yr 5yr 6yr
EB
WL
Follow UP
p vs Baseline always lt0001 BSG LSG
Bhandari M Mathur W etal In Print SOARD
CHOICE OF PROCEDURE
THREE YEARS SIX YEARS
THREE YEARS SIX YEARSLess than 50 50-75 above75 Less than 50 50-75 above75
BSG (0) 0 (2) 35 (56) 965 (0) 0 (4) 83 (44) 917
LSG (15)111 (66)474 (53)395 (46)469 (46)469 (9)91
0102030405060708090
100
BSG
LSG
3 YEARSLSG 111BSG 0
FAILURE RATE
6 YEARSLSG 469BSG 0
CHOICE OF PROCEDURE
CHOICE OF PROCEDURE
Bhandari M Mathur W Mishra A MBRSC Course May 2017 Indore India
The Gastric Bypass is the Gold Standard of Bariatric Metabolic Operations
RGBP BGBP
CHOICE OF PROCEDURE
COMPARISON OF BGBP VS STD GBP
Outcome after the operations BGBP STD GBP
Av Initial weight loss 1-3yrs gt77 65-70
Weight loss 4-10 years 70-77 55-65
Resolution of T2DM 80--85 60-80
VomitingSolid Food Intolerance 5-15 lt5
Significant Weight regain 3-7 10-35
Ringband Erosion 0-2 NA
CHOICE OF PROCEDURE
OAGBPMGB
One Anastamosis Gastric BypassMini Gastric Bypass (OAGBMGB)
Simplicity
Repeatability
Minimal Dissection
Reversibility
Exit Strategy
Safety
Minimal Suturing
Short Duration
Short Learning Curve
CHOICE OF PROCEDURE
OAGBSAGBMGB Advantagesbull Easier operation compared to Standard GBPbull Better food tolerancebull More weight loss than standard GBPbull Better weigh Loss Maintenancebull Higher metabolic effect on T2DM and Hyperlipidemiabull Less incidence of internal herniabull More options for revision if needed
Disadvantagesbull Bile reflux gastritis and esophagitisbull Marginal ulcersbull Nutrient deficienciesbull Protein Caloric Malnutrition
Quan Y Huanh A Ye M Efficacy of laproscopic mini gastric bypass for obesity and type 2 diabetes mellitus A systematic review and met-analysis Gastroenterol Res Pract 2015 ID 152852 10155
CHOICE OF PROCEDURE
2015 ndash Review articleVictorzon M et al Scand J Surg 2015 Mar104(1)48-53 Single-anastomosis gastric
bypass better faster and safer
bull The abstracts of 73 articles were reviewed and after removal of case studies duplicates and irrelevant articles 10 articles remained for closer review
bull Several thousand of this operation have been performed for more than 15 years It is claimed to be an easier safer faster and more effective metabolic operation compared to the standard Roux-en-Y gastric bypass The proponents of this operation also claim that this operation is easier to revise and reverse leaving more options compared to the situation after standard bypass in case of failure However there is much controversy surrounding this method mainly concerning the possible harmful and in the long-term even carcinogenic effects of biliopancreaticoduodenal reflux in the gastric pouch
Comment
Several thousands MGBs performed over 15 yrsEasier safer faster amp more effective than
RYGBEasier to revise amp reverse
Controversy regarding carcinogenic effect of BPD reflux
1306
1213
1294
1218
131
1207
114
116
118
12
122
124
126
128
13
132
Before After
BGB LGB MGB
Hemoglobin
RYGB VS Banded RYGB VS OAGBMGB
CHOICE OF PROCEDURE
399
372
394
36
396
352
32
33
34
35
36
37
38
39
4
41
Before After
BGB LGB MGB
Albumin661
644
693
67
685
607
56
58
6
62
64
66
68
7
Before After
BGB LGB MGB
Protein
RYGB VS Banded RYGB VS OAGBMGB
CHOICE OF PROCEDURE
911
87
906
873
909
833
78
8
82
84
86
88
9
92
Before After
BGB LGB MGB
Calcium
CHOICE OF PROCEDURE
RYGB VS Banded RYGB VS OAGBMGB
COMPARISON OF BGBP OAGB VS STD GBP
Outcome after the operations BGBP OAGBP STD GBP
Av Initial weight loss 1-3yrs gt77 gt77 65-70
Weight loss 4-10 years 70-77 70-77 55-65
Resolution of T2DM 80--85 80-90 60-80
VomitingSolid Food Intolerance 5-15 lt5 lt5
Diarrhea and Steatorrhea 1-2A 15-30 NA
Symptomatic Reflux 1-3 3-11 1-3
Marginal Ulcers 3-5 3-5 3-5
Protein Caloric Malnutrition lt1 3-11 lt1
Significant Weight regain 3-10 3-10 10-35
Ringband Erosion 0-1 NA NA
CHOICE OF PROCEDURE
We have enough information currently to enhance the outcome and minimize the risk by matching the operation to the patient
That is the basis forAn Algorithm for Bariatric Metabolic Operations
CHOOSING THE BEST BARIATRIC METABOLIC PROCEDURE FOR THE PATIENT
CHOICE OF PROCEDURE
bull All agesbull With no diabetesbull With low BMI preferably lt40bull With no GERDbull With HO PUDbull With HO or findings of liver diseasebull With Inflammatory bowel diseasebull With dense adhesions from multiple small bowel surgeriesbull Without HO VTEbull In heavy smokers who are not likely to quitbull In gastric cancer endemic areasbull High Risk needing minimal anesthesia and OR timebull High BMI gt 60 as part of a two stage approach
ALGORITHM
LSG BSG
CHOICE OF PROCEDURE
Laparoscopic Sleeve Gastrectomy Or Banded Sleeve Gastrostomy (SGBSD) Indicated for Patients
-All ages-Patients with T2DM lt5years and HbA1-c lt8 C-Peptidegt2 and not on insulin
-Patients with GERD
-ALL BMI ----- -BGBPBMIlt50-- LGBP
Vegetarian (BGBP)
BGBPLGBP
CHOICE OF PROCEDURE
ALGORITHM
Laparoscopic Gastric Bypass(LGBP) or Banded Gastric Bypass(BGBP) Indicated for Patients
bull With Diabetes gt5 years HbA1cgt8 C-Peptide lt2andor on Insulinbull All agesbull All BMI particularly High BMI-gt50bull High risk patients with need for short anesthesia timebull Because it is an easy to perform procedurebull Best tolerated by non Vegetarian
bull GERD Is a contraindicationbull Liver disease is a contraindication
Must be able to follow up patient regularlyPatient must be able to afford the required supplements OAGB
CHOICE OF PROCEDURE
ALGORITHM
OAGBMGB for patients
Sleeve gastrectomy with duodenal bypass(SGDJB) in patients with indication for Gastric Bypass in Gastric Cancer Endemic Areas
As effective as GBPSame weight loss andmetabolic effects as gastric bypass
SG-DJB
CHOICE OF PROCEDURE
ALGORITHM
Sleeve gastrectomy with duodenal bypass(SGDJB) in patients
1Second stage operation for the sleeve gastrectomy
2 Non responders or complications of sleeve gastric bypass or OAGBMGB
BPD-DS SADI SASI SG with enteral bypass
CHOICE OF PROCEDURE
ALGORITHM
BPD-DS SADI SAGI SASI) Indicated for
Areas with high incidence of anemia and very strict vegetarian food habits
CHOICE OF PROCEDURE
ALGORITHM
Sleeve Gastrectomy with gastro-jejunal gastro-ileal or entero-enteral anastomosis
Intra Gastric Balloon ENDOBARRIER
V-BLOC Aspire AssistEndoscopic Plication
For a patient who does not want an intra abdominal gastro-intestinal procedure
CHOICE OF PROCEDURE
Should You Do A Bariatric Metabolic Operation Because That Is What The Patient Wantsrdquo
NOYESmdashIt depends HoweverA bariatric metabolic surgeon should be able to offer the best operation for the patient based on the patientrsquos profile It is good practice to refer the patient to a tertiary center if the surgeon does not offer the operation that meets the patients indication
CHOICE OF PROCEDURE
CHOOSING THE BEST BARIATRIC METABOLIC PROCEDURE FOR THE PATIENT
CHOICE OF PROCEDURE
Case 157 yo Male BMI 57KgM2 T2DM GERD Strict Vegetarian
Algorithm
Gastric bypass-----Preferably Banded gastric bypassmdash------GERD Vegetarian
Not Sleeve because of T2DM GERD and High BMI
Not OAGBMGB because of GERD and probable of protein deficiency
CHOOSING THE BEST BARIATRIC METABOLIC PROCEDURE FOR THE PATIENT
CHOICE OF PROCEDURE
Case 1128 y0 F BMI 42 PCO DUB OSA and HO Migraine headaches
AlgorithmSleeve GastrectomymdashPreferably a Ring banded Sleeve gastrectomy
----No T2DM---No GERDNot Gastric bypass mdash anemia smelly flatus
Not OAGBMGB----Anemia Foul smelling flatus and body odor----Protein deficiency
CHOOSING THE BEST BARIATRIC METABOLIC PROCEDURE FOR THE PATIENT
CHOICE OF PROCEDURE
Case 11137 yo Male BMI 68 OSA OA and a non vegetarian who works at your hospitalReferred by the pulmonologist at your medical Centre
Algorithm
OAGBMGBmdashHigh BMI Non Veg-better food tolerance patient very likely to be followedand to afford the supplements because of proximity to your center
Not sleeve---poor weight loss with sleeve in super obeseNot Banded sleeve---Good weight loss but poor food tolerance since patient is a non vegetarianNot Gastric bypass---Weight loss in super obese have high non response after gastric bypass
and the gastric bypass is technically a more difficult operation than the OAGBNot Banded gastric bypass ndashGood weight loss but a BGBP is a more difficult operation and
the patient will have some food intolerance because of the ring
SURGICAL TREATMENT OPTIONS
At Mohak we perform these standard three operations and their banded modifications
Sleeve Gastrectomy Gastric Bypass OAGBMGB
CHOICE OF PROCEDURE
Evidence based operations performed at MBRSC From 2010 t0 2017---Standardized OperationsLaparoscopic Sleeve Gastrectomybull 90-120 cc Sleevebull 2-5cm from pylorusbull Where a sleeve is indicated but a band is contraindicated or not affordableBanded Sleeve Gastrectomy (BSG) 84 EWL after 60 monthsbull 90-120 cc Sleevebull 2-5cm from pylorusbull Ring 65-75 cmbull At 3-6 cm below GE junctionBanded Gastric bypass (BGBP) 75 EWL 48 monthsbull Create 6mdash7cm long pouchbull 65-75 cm ring at 3-5 cm below GE junction and gt2cm above anastomosisbull Large Gastroenterostomy gt 2cm bull 100cm Roux Limb and 80 cm BP limb for BMIlt50bull 100cm Roux Limb and 150 cm BP limb for BMIgt50Mini-Gastric Bypass (MGB) (OAGB) 79 EWL 60 monthsbull 9-18cm long pouch ~25cm widebull BP Limb length of 180cm BMIlt50Banded Mini-Gastric Bypass(BMGB)(BOAGB)bull 9-18cm long pouch ~25cm widebull Ring 7-75 cmbull BP Limb length of 180cm BMI50
THE MOHAK PROTOCOLStandardized Bariatric and Robotic Surgery Operations
CHOICE OF PROCEDURE
Sleeve Gastrectomy (LSG) or Banded Sleeve Gastrectomy (BSG)bull Non-diabeticsbull No hiatal hernia or GERDbull HO Smokingbull HO alcohol usebull HO PUDbull Abnormal LFTs NASH and early Cirrhosisbull Pts from areas with high incidence of gastric cancer of H pylori infectionbull High risks patients and super obese patients as part of a two-staged operation
Gastric Bypass (LGBP) or Banded Gastric Bypass (BGBP) or Hybrid BGBPMGBbull Have T2DM with HgbA1c lt 8 and duration lt 5 yearsbull Have Hiatal hernia or GERDbull Are Vegetarianbull No nicotine addiction (smoking)bull Have HO Alcohol intake bull Have NASH at surgery-No cirrhosisbull Not likely to come back for follow up andbull Revision operation of Failed Sleeve gastrectomy GBP or MGB
MOHAK ALGORITHM
CHOICE OF PROCEDURE
One Anastomosis Gastric Bypass-Mini-Gastric Bypass (OAGBP-MGB) bull Have T2DM with HgbA1c 8 and durationgt5 yearsbull Have No GERDbull Are Non-vegetarianbull Have poor dentitionbull Most likely to return for follow up at the clinicbull No HO alcohol intakebull No Nicotine addiction (smoking)bull Normal LFTsbull No NASH at surgery or cirrhosisbull Commitment by our program to have 100 follow up of theses patient
Revision Operationbull Sleeve to Banded RY with 100 cm Al limb and 180 cm BP Limbbull MGB to diverted MGB for Reflux Existing BPL and 100cm ALbull MGB to GBP for PCM or reversal to normal anatomy for PCMmdashinterim gastrostomy feedingbull GBP to BGBP with 180cm BP limb for Weight regain or inadequate weight loss BMIlt40bull GBP to BGBP with 300cm common limb for Weight regain or inadequate weight loss BMIgt40
MOHAK ALGORITHM
CHOICE OF PROCEDURE
bull Laparoscopic Gastric Bypass
bull Laparoscopic Sleeve Gastrectomy
bull Divided Mini-Gastric Bypass
bull Biliopancreatic Diversion with DS
bull Single Anastomosis Duodeno-ileostomy
bull Gastric Plication
bull Banded Gastric Plication
bull Endoscopic Gastroplasty
bull Laparoscopic Adjustable Gastric bands
bull Balloon Implantation
bull Ileal interposition
These other operations will be used selectively based on patients needs and the surgeons determination
CHOICE OF PROCEDURE
The MOHAK Guide for Choice of Bariatric Metabolic Surgery Operations
Single Incision Laparoscopic Robotic and Endoscopic approaches are
available at patientsrsquo requests and the discretion of the surgeon
CHOICE OF PROCEDURE
The MOHAK Guide for Choice of Bariatric Metabolic Surgery Operations
Mohak Bariatrics and Robotics Surgery Center Motto
ldquoThe best operation for the patient by a competent surgeon in a well equipped hospital to maximize outcomes with the least amount of risks exposurerdquo
WE ARE ABLE TO CHOOSE THE BEST BARIATRIC METABOLIC PROCEDURE FOR YOUR PATIENT
Good long-term results are our marketing toolSuccessful patients make a lot of referralsbull
CHOICE OF PROCEDURE
The MOHAK Guide for Choice of Bariatric Metabolic Surgery Operations
We offer various treatment modalities for obesity The operation is
determined by the profile of the patient and guided by findings from
analysis of the data from our prospectively maintained database
MOHAK TEAM INDORE INDIA
THANK YOU
Choice of Operation
PharmacotherapyDietingPhysical exerciseBehavioral modificationPsychotherapySurgical intervention
Treatment Options
Choice of Operation
PharmacotherapyDietingPhysical exerciseBehavioral modificationPsychotherapy
Treatment Options
Without surgery these options individually or in combination result in a high recidivism rate
CHOICE OF PROCEDURE
PharmacotherapyDietingPhysical exerciseBehavioral modificationPsychotherapySurgical intervention
A multidisciplinary approach including Surgical intervention provides the only long term option for treatment of obesity
TREATMENT OPTIONS
CHOICE OF PROCEDURE
ARMAMENTARIUM OF BARIATRIC METABOLIC PROCEDURES
bull The least effective current surgical
operation is many fold more effective
than any known non surgical treatment
SOS
Study
What we have learnt thus far
CHOICE OF PROCEDURE
CHOICE OF PROCEDURE
WHAT WE HAVE LEARNT THUS FAR
No one operation fits the needs of all patients
Choice of Operation
1 We currently have a better understanding of the Disease entity Obesity and the determining factors that affect the treatment of obesity
2 Mechanisms of action of various bariatric metabolic operations
AND
3 We know more about the operations---the relative contra-indications and the short and long-term outcomes of the various procedures
CHOICE OF PROCEDURE
THE DISEASE OBESITY
CHOICE OF PROCEDURE
THE DISEASE OBESITY
Obesity is a multi-system disease
Determining factors in the obese that affect the outcome of operations
Co morbid conditions
Risk factors in surgical treatment of obesity
CHOICE OF PROCEDURE
DETERMINING FACTORS
Genetics Expression of ObesityResponse to surgical treatment
Medical Metabolic syndrome T2DM CAD HO VTE Presence or absence of GERD Liver status and Mental Illness
Patient profile BMI Age GenderSocio-psycho-economic Factors
Smoking Alcohol intake Access to post op care Distance from care provider Cost of the operation-Cost and availability of equipment devices and suppliesAffordability of post operative care-Supplements-educational-financial status
DemographicEnvironmental factorsVegetarianAreas endemic to certain problemsmdashCancer UlcersCultural norms
MECHANISMS OF ACTION OF VARIOUS BARIATRIC METABOLIC OPERATIONS
bull Restrictive Effect Control the reservoir size
bull Neural Stimulation of G-E full sense effectsatiation
bull Patient Compliance Forced behavior modification Motivation fear dyspepsia physical activity dietary habit alteration support group participation and physician contact
bull Malabsorptive Effect Bypassed segment of the GI tract results in mal absorption
bull Dumping Effect High caloric fluid and fatty food intolerance
bull Ghrelin Effect Anorexia
bull Foregut effect GIP PYY and Leptin effects
bull Hindgut effect GLP-I motilityNauseasatiation
bull Microbiota effect alteration of the bacterial flora of the gut alters absorption
bull Bile salts
CHOICE OF PROCEDURE
Currently known mechanisms responsible for the effects of the various bariatric metabolic operations include but not limited to
Outcomes of the various operationsWeight Loss and maintenanceResolution of co-morbid conditions---Contra-indications to the various operations--Complications inherent in the operations----
CHOICE OF PROCEDURE
bull Refluxbull Ulcersbull Nutrient deficienciesbull Protein caloric malnutritionbull DiarrheaSteatorrheabull Food Intolerancebull RingBand Migration
The Operations and Procedures
SURGICAL TREATMENT OPTIONS
A Bariatric Metabolic Surgeon should be able to Perform these three basic procedures and their modifications
Sleeve Gastrectomy Gastric Bypass OAGBMGB
CHOICE OF PROCEDURE
CHOICE OF PROCEDURE
Sleeve Gastrectomy Ring BandedSleeve Gastrectomy
The Ring Stabilizes The Size of The Sleeveand minimizes the disadvantagesSEEVE GASTRECTOMY
1 Relatively simple operation2 No disruption of gastrointestinal tract3 No gastro-intestinal anastomosis4 Nearly regular intestinal absorption 5 Low incidence of dumping syndrome6 0 risk of developing an internal hernia 7 Good weight loss and resolution of
co-morbid conditions almost equal to GBP
Disadvantages-Weight loss ltLGBP-Dilation of sleeve with weight regain and recurrence of co-morbid conditions
-Neo-reflux-Intractable leaks-Torsionstenosis-Porto-mesenteric thrombosis
CHOICE OF PROCEDURE
Sleeve Gastrectomy
Ring BandedSleeve Gastrectomy
06M 1 yr 2yr 3yr 4yr 5yr 6yr
EB
WL
Follow UP
p vs Baseline always lt0001 BSG LSG
Bhandari M Mathur W etal In Print SOARD
CHOICE OF PROCEDURE
THREE YEARS SIX YEARS
THREE YEARS SIX YEARSLess than 50 50-75 above75 Less than 50 50-75 above75
BSG (0) 0 (2) 35 (56) 965 (0) 0 (4) 83 (44) 917
LSG (15)111 (66)474 (53)395 (46)469 (46)469 (9)91
0102030405060708090
100
BSG
LSG
3 YEARSLSG 111BSG 0
FAILURE RATE
6 YEARSLSG 469BSG 0
CHOICE OF PROCEDURE
CHOICE OF PROCEDURE
Bhandari M Mathur W Mishra A MBRSC Course May 2017 Indore India
The Gastric Bypass is the Gold Standard of Bariatric Metabolic Operations
RGBP BGBP
CHOICE OF PROCEDURE
COMPARISON OF BGBP VS STD GBP
Outcome after the operations BGBP STD GBP
Av Initial weight loss 1-3yrs gt77 65-70
Weight loss 4-10 years 70-77 55-65
Resolution of T2DM 80--85 60-80
VomitingSolid Food Intolerance 5-15 lt5
Significant Weight regain 3-7 10-35
Ringband Erosion 0-2 NA
CHOICE OF PROCEDURE
OAGBPMGB
One Anastamosis Gastric BypassMini Gastric Bypass (OAGBMGB)
Simplicity
Repeatability
Minimal Dissection
Reversibility
Exit Strategy
Safety
Minimal Suturing
Short Duration
Short Learning Curve
CHOICE OF PROCEDURE
OAGBSAGBMGB Advantagesbull Easier operation compared to Standard GBPbull Better food tolerancebull More weight loss than standard GBPbull Better weigh Loss Maintenancebull Higher metabolic effect on T2DM and Hyperlipidemiabull Less incidence of internal herniabull More options for revision if needed
Disadvantagesbull Bile reflux gastritis and esophagitisbull Marginal ulcersbull Nutrient deficienciesbull Protein Caloric Malnutrition
Quan Y Huanh A Ye M Efficacy of laproscopic mini gastric bypass for obesity and type 2 diabetes mellitus A systematic review and met-analysis Gastroenterol Res Pract 2015 ID 152852 10155
CHOICE OF PROCEDURE
2015 ndash Review articleVictorzon M et al Scand J Surg 2015 Mar104(1)48-53 Single-anastomosis gastric
bypass better faster and safer
bull The abstracts of 73 articles were reviewed and after removal of case studies duplicates and irrelevant articles 10 articles remained for closer review
bull Several thousand of this operation have been performed for more than 15 years It is claimed to be an easier safer faster and more effective metabolic operation compared to the standard Roux-en-Y gastric bypass The proponents of this operation also claim that this operation is easier to revise and reverse leaving more options compared to the situation after standard bypass in case of failure However there is much controversy surrounding this method mainly concerning the possible harmful and in the long-term even carcinogenic effects of biliopancreaticoduodenal reflux in the gastric pouch
Comment
Several thousands MGBs performed over 15 yrsEasier safer faster amp more effective than
RYGBEasier to revise amp reverse
Controversy regarding carcinogenic effect of BPD reflux
1306
1213
1294
1218
131
1207
114
116
118
12
122
124
126
128
13
132
Before After
BGB LGB MGB
Hemoglobin
RYGB VS Banded RYGB VS OAGBMGB
CHOICE OF PROCEDURE
399
372
394
36
396
352
32
33
34
35
36
37
38
39
4
41
Before After
BGB LGB MGB
Albumin661
644
693
67
685
607
56
58
6
62
64
66
68
7
Before After
BGB LGB MGB
Protein
RYGB VS Banded RYGB VS OAGBMGB
CHOICE OF PROCEDURE
911
87
906
873
909
833
78
8
82
84
86
88
9
92
Before After
BGB LGB MGB
Calcium
CHOICE OF PROCEDURE
RYGB VS Banded RYGB VS OAGBMGB
COMPARISON OF BGBP OAGB VS STD GBP
Outcome after the operations BGBP OAGBP STD GBP
Av Initial weight loss 1-3yrs gt77 gt77 65-70
Weight loss 4-10 years 70-77 70-77 55-65
Resolution of T2DM 80--85 80-90 60-80
VomitingSolid Food Intolerance 5-15 lt5 lt5
Diarrhea and Steatorrhea 1-2A 15-30 NA
Symptomatic Reflux 1-3 3-11 1-3
Marginal Ulcers 3-5 3-5 3-5
Protein Caloric Malnutrition lt1 3-11 lt1
Significant Weight regain 3-10 3-10 10-35
Ringband Erosion 0-1 NA NA
CHOICE OF PROCEDURE
We have enough information currently to enhance the outcome and minimize the risk by matching the operation to the patient
That is the basis forAn Algorithm for Bariatric Metabolic Operations
CHOOSING THE BEST BARIATRIC METABOLIC PROCEDURE FOR THE PATIENT
CHOICE OF PROCEDURE
bull All agesbull With no diabetesbull With low BMI preferably lt40bull With no GERDbull With HO PUDbull With HO or findings of liver diseasebull With Inflammatory bowel diseasebull With dense adhesions from multiple small bowel surgeriesbull Without HO VTEbull In heavy smokers who are not likely to quitbull In gastric cancer endemic areasbull High Risk needing minimal anesthesia and OR timebull High BMI gt 60 as part of a two stage approach
ALGORITHM
LSG BSG
CHOICE OF PROCEDURE
Laparoscopic Sleeve Gastrectomy Or Banded Sleeve Gastrostomy (SGBSD) Indicated for Patients
-All ages-Patients with T2DM lt5years and HbA1-c lt8 C-Peptidegt2 and not on insulin
-Patients with GERD
-ALL BMI ----- -BGBPBMIlt50-- LGBP
Vegetarian (BGBP)
BGBPLGBP
CHOICE OF PROCEDURE
ALGORITHM
Laparoscopic Gastric Bypass(LGBP) or Banded Gastric Bypass(BGBP) Indicated for Patients
bull With Diabetes gt5 years HbA1cgt8 C-Peptide lt2andor on Insulinbull All agesbull All BMI particularly High BMI-gt50bull High risk patients with need for short anesthesia timebull Because it is an easy to perform procedurebull Best tolerated by non Vegetarian
bull GERD Is a contraindicationbull Liver disease is a contraindication
Must be able to follow up patient regularlyPatient must be able to afford the required supplements OAGB
CHOICE OF PROCEDURE
ALGORITHM
OAGBMGB for patients
Sleeve gastrectomy with duodenal bypass(SGDJB) in patients with indication for Gastric Bypass in Gastric Cancer Endemic Areas
As effective as GBPSame weight loss andmetabolic effects as gastric bypass
SG-DJB
CHOICE OF PROCEDURE
ALGORITHM
Sleeve gastrectomy with duodenal bypass(SGDJB) in patients
1Second stage operation for the sleeve gastrectomy
2 Non responders or complications of sleeve gastric bypass or OAGBMGB
BPD-DS SADI SASI SG with enteral bypass
CHOICE OF PROCEDURE
ALGORITHM
BPD-DS SADI SAGI SASI) Indicated for
Areas with high incidence of anemia and very strict vegetarian food habits
CHOICE OF PROCEDURE
ALGORITHM
Sleeve Gastrectomy with gastro-jejunal gastro-ileal or entero-enteral anastomosis
Intra Gastric Balloon ENDOBARRIER
V-BLOC Aspire AssistEndoscopic Plication
For a patient who does not want an intra abdominal gastro-intestinal procedure
CHOICE OF PROCEDURE
Should You Do A Bariatric Metabolic Operation Because That Is What The Patient Wantsrdquo
NOYESmdashIt depends HoweverA bariatric metabolic surgeon should be able to offer the best operation for the patient based on the patientrsquos profile It is good practice to refer the patient to a tertiary center if the surgeon does not offer the operation that meets the patients indication
CHOICE OF PROCEDURE
CHOOSING THE BEST BARIATRIC METABOLIC PROCEDURE FOR THE PATIENT
CHOICE OF PROCEDURE
Case 157 yo Male BMI 57KgM2 T2DM GERD Strict Vegetarian
Algorithm
Gastric bypass-----Preferably Banded gastric bypassmdash------GERD Vegetarian
Not Sleeve because of T2DM GERD and High BMI
Not OAGBMGB because of GERD and probable of protein deficiency
CHOOSING THE BEST BARIATRIC METABOLIC PROCEDURE FOR THE PATIENT
CHOICE OF PROCEDURE
Case 1128 y0 F BMI 42 PCO DUB OSA and HO Migraine headaches
AlgorithmSleeve GastrectomymdashPreferably a Ring banded Sleeve gastrectomy
----No T2DM---No GERDNot Gastric bypass mdash anemia smelly flatus
Not OAGBMGB----Anemia Foul smelling flatus and body odor----Protein deficiency
CHOOSING THE BEST BARIATRIC METABOLIC PROCEDURE FOR THE PATIENT
CHOICE OF PROCEDURE
Case 11137 yo Male BMI 68 OSA OA and a non vegetarian who works at your hospitalReferred by the pulmonologist at your medical Centre
Algorithm
OAGBMGBmdashHigh BMI Non Veg-better food tolerance patient very likely to be followedand to afford the supplements because of proximity to your center
Not sleeve---poor weight loss with sleeve in super obeseNot Banded sleeve---Good weight loss but poor food tolerance since patient is a non vegetarianNot Gastric bypass---Weight loss in super obese have high non response after gastric bypass
and the gastric bypass is technically a more difficult operation than the OAGBNot Banded gastric bypass ndashGood weight loss but a BGBP is a more difficult operation and
the patient will have some food intolerance because of the ring
SURGICAL TREATMENT OPTIONS
At Mohak we perform these standard three operations and their banded modifications
Sleeve Gastrectomy Gastric Bypass OAGBMGB
CHOICE OF PROCEDURE
Evidence based operations performed at MBRSC From 2010 t0 2017---Standardized OperationsLaparoscopic Sleeve Gastrectomybull 90-120 cc Sleevebull 2-5cm from pylorusbull Where a sleeve is indicated but a band is contraindicated or not affordableBanded Sleeve Gastrectomy (BSG) 84 EWL after 60 monthsbull 90-120 cc Sleevebull 2-5cm from pylorusbull Ring 65-75 cmbull At 3-6 cm below GE junctionBanded Gastric bypass (BGBP) 75 EWL 48 monthsbull Create 6mdash7cm long pouchbull 65-75 cm ring at 3-5 cm below GE junction and gt2cm above anastomosisbull Large Gastroenterostomy gt 2cm bull 100cm Roux Limb and 80 cm BP limb for BMIlt50bull 100cm Roux Limb and 150 cm BP limb for BMIgt50Mini-Gastric Bypass (MGB) (OAGB) 79 EWL 60 monthsbull 9-18cm long pouch ~25cm widebull BP Limb length of 180cm BMIlt50Banded Mini-Gastric Bypass(BMGB)(BOAGB)bull 9-18cm long pouch ~25cm widebull Ring 7-75 cmbull BP Limb length of 180cm BMI50
THE MOHAK PROTOCOLStandardized Bariatric and Robotic Surgery Operations
CHOICE OF PROCEDURE
Sleeve Gastrectomy (LSG) or Banded Sleeve Gastrectomy (BSG)bull Non-diabeticsbull No hiatal hernia or GERDbull HO Smokingbull HO alcohol usebull HO PUDbull Abnormal LFTs NASH and early Cirrhosisbull Pts from areas with high incidence of gastric cancer of H pylori infectionbull High risks patients and super obese patients as part of a two-staged operation
Gastric Bypass (LGBP) or Banded Gastric Bypass (BGBP) or Hybrid BGBPMGBbull Have T2DM with HgbA1c lt 8 and duration lt 5 yearsbull Have Hiatal hernia or GERDbull Are Vegetarianbull No nicotine addiction (smoking)bull Have HO Alcohol intake bull Have NASH at surgery-No cirrhosisbull Not likely to come back for follow up andbull Revision operation of Failed Sleeve gastrectomy GBP or MGB
MOHAK ALGORITHM
CHOICE OF PROCEDURE
One Anastomosis Gastric Bypass-Mini-Gastric Bypass (OAGBP-MGB) bull Have T2DM with HgbA1c 8 and durationgt5 yearsbull Have No GERDbull Are Non-vegetarianbull Have poor dentitionbull Most likely to return for follow up at the clinicbull No HO alcohol intakebull No Nicotine addiction (smoking)bull Normal LFTsbull No NASH at surgery or cirrhosisbull Commitment by our program to have 100 follow up of theses patient
Revision Operationbull Sleeve to Banded RY with 100 cm Al limb and 180 cm BP Limbbull MGB to diverted MGB for Reflux Existing BPL and 100cm ALbull MGB to GBP for PCM or reversal to normal anatomy for PCMmdashinterim gastrostomy feedingbull GBP to BGBP with 180cm BP limb for Weight regain or inadequate weight loss BMIlt40bull GBP to BGBP with 300cm common limb for Weight regain or inadequate weight loss BMIgt40
MOHAK ALGORITHM
CHOICE OF PROCEDURE
bull Laparoscopic Gastric Bypass
bull Laparoscopic Sleeve Gastrectomy
bull Divided Mini-Gastric Bypass
bull Biliopancreatic Diversion with DS
bull Single Anastomosis Duodeno-ileostomy
bull Gastric Plication
bull Banded Gastric Plication
bull Endoscopic Gastroplasty
bull Laparoscopic Adjustable Gastric bands
bull Balloon Implantation
bull Ileal interposition
These other operations will be used selectively based on patients needs and the surgeons determination
CHOICE OF PROCEDURE
The MOHAK Guide for Choice of Bariatric Metabolic Surgery Operations
Single Incision Laparoscopic Robotic and Endoscopic approaches are
available at patientsrsquo requests and the discretion of the surgeon
CHOICE OF PROCEDURE
The MOHAK Guide for Choice of Bariatric Metabolic Surgery Operations
Mohak Bariatrics and Robotics Surgery Center Motto
ldquoThe best operation for the patient by a competent surgeon in a well equipped hospital to maximize outcomes with the least amount of risks exposurerdquo
WE ARE ABLE TO CHOOSE THE BEST BARIATRIC METABOLIC PROCEDURE FOR YOUR PATIENT
Good long-term results are our marketing toolSuccessful patients make a lot of referralsbull
CHOICE OF PROCEDURE
The MOHAK Guide for Choice of Bariatric Metabolic Surgery Operations
We offer various treatment modalities for obesity The operation is
determined by the profile of the patient and guided by findings from
analysis of the data from our prospectively maintained database
MOHAK TEAM INDORE INDIA
THANK YOU
Choice of Operation
PharmacotherapyDietingPhysical exerciseBehavioral modificationPsychotherapy
Treatment Options
Without surgery these options individually or in combination result in a high recidivism rate
CHOICE OF PROCEDURE
PharmacotherapyDietingPhysical exerciseBehavioral modificationPsychotherapySurgical intervention
A multidisciplinary approach including Surgical intervention provides the only long term option for treatment of obesity
TREATMENT OPTIONS
CHOICE OF PROCEDURE
ARMAMENTARIUM OF BARIATRIC METABOLIC PROCEDURES
bull The least effective current surgical
operation is many fold more effective
than any known non surgical treatment
SOS
Study
What we have learnt thus far
CHOICE OF PROCEDURE
CHOICE OF PROCEDURE
WHAT WE HAVE LEARNT THUS FAR
No one operation fits the needs of all patients
Choice of Operation
1 We currently have a better understanding of the Disease entity Obesity and the determining factors that affect the treatment of obesity
2 Mechanisms of action of various bariatric metabolic operations
AND
3 We know more about the operations---the relative contra-indications and the short and long-term outcomes of the various procedures
CHOICE OF PROCEDURE
THE DISEASE OBESITY
CHOICE OF PROCEDURE
THE DISEASE OBESITY
Obesity is a multi-system disease
Determining factors in the obese that affect the outcome of operations
Co morbid conditions
Risk factors in surgical treatment of obesity
CHOICE OF PROCEDURE
DETERMINING FACTORS
Genetics Expression of ObesityResponse to surgical treatment
Medical Metabolic syndrome T2DM CAD HO VTE Presence or absence of GERD Liver status and Mental Illness
Patient profile BMI Age GenderSocio-psycho-economic Factors
Smoking Alcohol intake Access to post op care Distance from care provider Cost of the operation-Cost and availability of equipment devices and suppliesAffordability of post operative care-Supplements-educational-financial status
DemographicEnvironmental factorsVegetarianAreas endemic to certain problemsmdashCancer UlcersCultural norms
MECHANISMS OF ACTION OF VARIOUS BARIATRIC METABOLIC OPERATIONS
bull Restrictive Effect Control the reservoir size
bull Neural Stimulation of G-E full sense effectsatiation
bull Patient Compliance Forced behavior modification Motivation fear dyspepsia physical activity dietary habit alteration support group participation and physician contact
bull Malabsorptive Effect Bypassed segment of the GI tract results in mal absorption
bull Dumping Effect High caloric fluid and fatty food intolerance
bull Ghrelin Effect Anorexia
bull Foregut effect GIP PYY and Leptin effects
bull Hindgut effect GLP-I motilityNauseasatiation
bull Microbiota effect alteration of the bacterial flora of the gut alters absorption
bull Bile salts
CHOICE OF PROCEDURE
Currently known mechanisms responsible for the effects of the various bariatric metabolic operations include but not limited to
Outcomes of the various operationsWeight Loss and maintenanceResolution of co-morbid conditions---Contra-indications to the various operations--Complications inherent in the operations----
CHOICE OF PROCEDURE
bull Refluxbull Ulcersbull Nutrient deficienciesbull Protein caloric malnutritionbull DiarrheaSteatorrheabull Food Intolerancebull RingBand Migration
The Operations and Procedures
SURGICAL TREATMENT OPTIONS
A Bariatric Metabolic Surgeon should be able to Perform these three basic procedures and their modifications
Sleeve Gastrectomy Gastric Bypass OAGBMGB
CHOICE OF PROCEDURE
CHOICE OF PROCEDURE
Sleeve Gastrectomy Ring BandedSleeve Gastrectomy
The Ring Stabilizes The Size of The Sleeveand minimizes the disadvantagesSEEVE GASTRECTOMY
1 Relatively simple operation2 No disruption of gastrointestinal tract3 No gastro-intestinal anastomosis4 Nearly regular intestinal absorption 5 Low incidence of dumping syndrome6 0 risk of developing an internal hernia 7 Good weight loss and resolution of
co-morbid conditions almost equal to GBP
Disadvantages-Weight loss ltLGBP-Dilation of sleeve with weight regain and recurrence of co-morbid conditions
-Neo-reflux-Intractable leaks-Torsionstenosis-Porto-mesenteric thrombosis
CHOICE OF PROCEDURE
Sleeve Gastrectomy
Ring BandedSleeve Gastrectomy
06M 1 yr 2yr 3yr 4yr 5yr 6yr
EB
WL
Follow UP
p vs Baseline always lt0001 BSG LSG
Bhandari M Mathur W etal In Print SOARD
CHOICE OF PROCEDURE
THREE YEARS SIX YEARS
THREE YEARS SIX YEARSLess than 50 50-75 above75 Less than 50 50-75 above75
BSG (0) 0 (2) 35 (56) 965 (0) 0 (4) 83 (44) 917
LSG (15)111 (66)474 (53)395 (46)469 (46)469 (9)91
0102030405060708090
100
BSG
LSG
3 YEARSLSG 111BSG 0
FAILURE RATE
6 YEARSLSG 469BSG 0
CHOICE OF PROCEDURE
CHOICE OF PROCEDURE
Bhandari M Mathur W Mishra A MBRSC Course May 2017 Indore India
The Gastric Bypass is the Gold Standard of Bariatric Metabolic Operations
RGBP BGBP
CHOICE OF PROCEDURE
COMPARISON OF BGBP VS STD GBP
Outcome after the operations BGBP STD GBP
Av Initial weight loss 1-3yrs gt77 65-70
Weight loss 4-10 years 70-77 55-65
Resolution of T2DM 80--85 60-80
VomitingSolid Food Intolerance 5-15 lt5
Significant Weight regain 3-7 10-35
Ringband Erosion 0-2 NA
CHOICE OF PROCEDURE
OAGBPMGB
One Anastamosis Gastric BypassMini Gastric Bypass (OAGBMGB)
Simplicity
Repeatability
Minimal Dissection
Reversibility
Exit Strategy
Safety
Minimal Suturing
Short Duration
Short Learning Curve
CHOICE OF PROCEDURE
OAGBSAGBMGB Advantagesbull Easier operation compared to Standard GBPbull Better food tolerancebull More weight loss than standard GBPbull Better weigh Loss Maintenancebull Higher metabolic effect on T2DM and Hyperlipidemiabull Less incidence of internal herniabull More options for revision if needed
Disadvantagesbull Bile reflux gastritis and esophagitisbull Marginal ulcersbull Nutrient deficienciesbull Protein Caloric Malnutrition
Quan Y Huanh A Ye M Efficacy of laproscopic mini gastric bypass for obesity and type 2 diabetes mellitus A systematic review and met-analysis Gastroenterol Res Pract 2015 ID 152852 10155
CHOICE OF PROCEDURE
2015 ndash Review articleVictorzon M et al Scand J Surg 2015 Mar104(1)48-53 Single-anastomosis gastric
bypass better faster and safer
bull The abstracts of 73 articles were reviewed and after removal of case studies duplicates and irrelevant articles 10 articles remained for closer review
bull Several thousand of this operation have been performed for more than 15 years It is claimed to be an easier safer faster and more effective metabolic operation compared to the standard Roux-en-Y gastric bypass The proponents of this operation also claim that this operation is easier to revise and reverse leaving more options compared to the situation after standard bypass in case of failure However there is much controversy surrounding this method mainly concerning the possible harmful and in the long-term even carcinogenic effects of biliopancreaticoduodenal reflux in the gastric pouch
Comment
Several thousands MGBs performed over 15 yrsEasier safer faster amp more effective than
RYGBEasier to revise amp reverse
Controversy regarding carcinogenic effect of BPD reflux
1306
1213
1294
1218
131
1207
114
116
118
12
122
124
126
128
13
132
Before After
BGB LGB MGB
Hemoglobin
RYGB VS Banded RYGB VS OAGBMGB
CHOICE OF PROCEDURE
399
372
394
36
396
352
32
33
34
35
36
37
38
39
4
41
Before After
BGB LGB MGB
Albumin661
644
693
67
685
607
56
58
6
62
64
66
68
7
Before After
BGB LGB MGB
Protein
RYGB VS Banded RYGB VS OAGBMGB
CHOICE OF PROCEDURE
911
87
906
873
909
833
78
8
82
84
86
88
9
92
Before After
BGB LGB MGB
Calcium
CHOICE OF PROCEDURE
RYGB VS Banded RYGB VS OAGBMGB
COMPARISON OF BGBP OAGB VS STD GBP
Outcome after the operations BGBP OAGBP STD GBP
Av Initial weight loss 1-3yrs gt77 gt77 65-70
Weight loss 4-10 years 70-77 70-77 55-65
Resolution of T2DM 80--85 80-90 60-80
VomitingSolid Food Intolerance 5-15 lt5 lt5
Diarrhea and Steatorrhea 1-2A 15-30 NA
Symptomatic Reflux 1-3 3-11 1-3
Marginal Ulcers 3-5 3-5 3-5
Protein Caloric Malnutrition lt1 3-11 lt1
Significant Weight regain 3-10 3-10 10-35
Ringband Erosion 0-1 NA NA
CHOICE OF PROCEDURE
We have enough information currently to enhance the outcome and minimize the risk by matching the operation to the patient
That is the basis forAn Algorithm for Bariatric Metabolic Operations
CHOOSING THE BEST BARIATRIC METABOLIC PROCEDURE FOR THE PATIENT
CHOICE OF PROCEDURE
bull All agesbull With no diabetesbull With low BMI preferably lt40bull With no GERDbull With HO PUDbull With HO or findings of liver diseasebull With Inflammatory bowel diseasebull With dense adhesions from multiple small bowel surgeriesbull Without HO VTEbull In heavy smokers who are not likely to quitbull In gastric cancer endemic areasbull High Risk needing minimal anesthesia and OR timebull High BMI gt 60 as part of a two stage approach
ALGORITHM
LSG BSG
CHOICE OF PROCEDURE
Laparoscopic Sleeve Gastrectomy Or Banded Sleeve Gastrostomy (SGBSD) Indicated for Patients
-All ages-Patients with T2DM lt5years and HbA1-c lt8 C-Peptidegt2 and not on insulin
-Patients with GERD
-ALL BMI ----- -BGBPBMIlt50-- LGBP
Vegetarian (BGBP)
BGBPLGBP
CHOICE OF PROCEDURE
ALGORITHM
Laparoscopic Gastric Bypass(LGBP) or Banded Gastric Bypass(BGBP) Indicated for Patients
bull With Diabetes gt5 years HbA1cgt8 C-Peptide lt2andor on Insulinbull All agesbull All BMI particularly High BMI-gt50bull High risk patients with need for short anesthesia timebull Because it is an easy to perform procedurebull Best tolerated by non Vegetarian
bull GERD Is a contraindicationbull Liver disease is a contraindication
Must be able to follow up patient regularlyPatient must be able to afford the required supplements OAGB
CHOICE OF PROCEDURE
ALGORITHM
OAGBMGB for patients
Sleeve gastrectomy with duodenal bypass(SGDJB) in patients with indication for Gastric Bypass in Gastric Cancer Endemic Areas
As effective as GBPSame weight loss andmetabolic effects as gastric bypass
SG-DJB
CHOICE OF PROCEDURE
ALGORITHM
Sleeve gastrectomy with duodenal bypass(SGDJB) in patients
1Second stage operation for the sleeve gastrectomy
2 Non responders or complications of sleeve gastric bypass or OAGBMGB
BPD-DS SADI SASI SG with enteral bypass
CHOICE OF PROCEDURE
ALGORITHM
BPD-DS SADI SAGI SASI) Indicated for
Areas with high incidence of anemia and very strict vegetarian food habits
CHOICE OF PROCEDURE
ALGORITHM
Sleeve Gastrectomy with gastro-jejunal gastro-ileal or entero-enteral anastomosis
Intra Gastric Balloon ENDOBARRIER
V-BLOC Aspire AssistEndoscopic Plication
For a patient who does not want an intra abdominal gastro-intestinal procedure
CHOICE OF PROCEDURE
Should You Do A Bariatric Metabolic Operation Because That Is What The Patient Wantsrdquo
NOYESmdashIt depends HoweverA bariatric metabolic surgeon should be able to offer the best operation for the patient based on the patientrsquos profile It is good practice to refer the patient to a tertiary center if the surgeon does not offer the operation that meets the patients indication
CHOICE OF PROCEDURE
CHOOSING THE BEST BARIATRIC METABOLIC PROCEDURE FOR THE PATIENT
CHOICE OF PROCEDURE
Case 157 yo Male BMI 57KgM2 T2DM GERD Strict Vegetarian
Algorithm
Gastric bypass-----Preferably Banded gastric bypassmdash------GERD Vegetarian
Not Sleeve because of T2DM GERD and High BMI
Not OAGBMGB because of GERD and probable of protein deficiency
CHOOSING THE BEST BARIATRIC METABOLIC PROCEDURE FOR THE PATIENT
CHOICE OF PROCEDURE
Case 1128 y0 F BMI 42 PCO DUB OSA and HO Migraine headaches
AlgorithmSleeve GastrectomymdashPreferably a Ring banded Sleeve gastrectomy
----No T2DM---No GERDNot Gastric bypass mdash anemia smelly flatus
Not OAGBMGB----Anemia Foul smelling flatus and body odor----Protein deficiency
CHOOSING THE BEST BARIATRIC METABOLIC PROCEDURE FOR THE PATIENT
CHOICE OF PROCEDURE
Case 11137 yo Male BMI 68 OSA OA and a non vegetarian who works at your hospitalReferred by the pulmonologist at your medical Centre
Algorithm
OAGBMGBmdashHigh BMI Non Veg-better food tolerance patient very likely to be followedand to afford the supplements because of proximity to your center
Not sleeve---poor weight loss with sleeve in super obeseNot Banded sleeve---Good weight loss but poor food tolerance since patient is a non vegetarianNot Gastric bypass---Weight loss in super obese have high non response after gastric bypass
and the gastric bypass is technically a more difficult operation than the OAGBNot Banded gastric bypass ndashGood weight loss but a BGBP is a more difficult operation and
the patient will have some food intolerance because of the ring
SURGICAL TREATMENT OPTIONS
At Mohak we perform these standard three operations and their banded modifications
Sleeve Gastrectomy Gastric Bypass OAGBMGB
CHOICE OF PROCEDURE
Evidence based operations performed at MBRSC From 2010 t0 2017---Standardized OperationsLaparoscopic Sleeve Gastrectomybull 90-120 cc Sleevebull 2-5cm from pylorusbull Where a sleeve is indicated but a band is contraindicated or not affordableBanded Sleeve Gastrectomy (BSG) 84 EWL after 60 monthsbull 90-120 cc Sleevebull 2-5cm from pylorusbull Ring 65-75 cmbull At 3-6 cm below GE junctionBanded Gastric bypass (BGBP) 75 EWL 48 monthsbull Create 6mdash7cm long pouchbull 65-75 cm ring at 3-5 cm below GE junction and gt2cm above anastomosisbull Large Gastroenterostomy gt 2cm bull 100cm Roux Limb and 80 cm BP limb for BMIlt50bull 100cm Roux Limb and 150 cm BP limb for BMIgt50Mini-Gastric Bypass (MGB) (OAGB) 79 EWL 60 monthsbull 9-18cm long pouch ~25cm widebull BP Limb length of 180cm BMIlt50Banded Mini-Gastric Bypass(BMGB)(BOAGB)bull 9-18cm long pouch ~25cm widebull Ring 7-75 cmbull BP Limb length of 180cm BMI50
THE MOHAK PROTOCOLStandardized Bariatric and Robotic Surgery Operations
CHOICE OF PROCEDURE
Sleeve Gastrectomy (LSG) or Banded Sleeve Gastrectomy (BSG)bull Non-diabeticsbull No hiatal hernia or GERDbull HO Smokingbull HO alcohol usebull HO PUDbull Abnormal LFTs NASH and early Cirrhosisbull Pts from areas with high incidence of gastric cancer of H pylori infectionbull High risks patients and super obese patients as part of a two-staged operation
Gastric Bypass (LGBP) or Banded Gastric Bypass (BGBP) or Hybrid BGBPMGBbull Have T2DM with HgbA1c lt 8 and duration lt 5 yearsbull Have Hiatal hernia or GERDbull Are Vegetarianbull No nicotine addiction (smoking)bull Have HO Alcohol intake bull Have NASH at surgery-No cirrhosisbull Not likely to come back for follow up andbull Revision operation of Failed Sleeve gastrectomy GBP or MGB
MOHAK ALGORITHM
CHOICE OF PROCEDURE
One Anastomosis Gastric Bypass-Mini-Gastric Bypass (OAGBP-MGB) bull Have T2DM with HgbA1c 8 and durationgt5 yearsbull Have No GERDbull Are Non-vegetarianbull Have poor dentitionbull Most likely to return for follow up at the clinicbull No HO alcohol intakebull No Nicotine addiction (smoking)bull Normal LFTsbull No NASH at surgery or cirrhosisbull Commitment by our program to have 100 follow up of theses patient
Revision Operationbull Sleeve to Banded RY with 100 cm Al limb and 180 cm BP Limbbull MGB to diverted MGB for Reflux Existing BPL and 100cm ALbull MGB to GBP for PCM or reversal to normal anatomy for PCMmdashinterim gastrostomy feedingbull GBP to BGBP with 180cm BP limb for Weight regain or inadequate weight loss BMIlt40bull GBP to BGBP with 300cm common limb for Weight regain or inadequate weight loss BMIgt40
MOHAK ALGORITHM
CHOICE OF PROCEDURE
bull Laparoscopic Gastric Bypass
bull Laparoscopic Sleeve Gastrectomy
bull Divided Mini-Gastric Bypass
bull Biliopancreatic Diversion with DS
bull Single Anastomosis Duodeno-ileostomy
bull Gastric Plication
bull Banded Gastric Plication
bull Endoscopic Gastroplasty
bull Laparoscopic Adjustable Gastric bands
bull Balloon Implantation
bull Ileal interposition
These other operations will be used selectively based on patients needs and the surgeons determination
CHOICE OF PROCEDURE
The MOHAK Guide for Choice of Bariatric Metabolic Surgery Operations
Single Incision Laparoscopic Robotic and Endoscopic approaches are
available at patientsrsquo requests and the discretion of the surgeon
CHOICE OF PROCEDURE
The MOHAK Guide for Choice of Bariatric Metabolic Surgery Operations
Mohak Bariatrics and Robotics Surgery Center Motto
ldquoThe best operation for the patient by a competent surgeon in a well equipped hospital to maximize outcomes with the least amount of risks exposurerdquo
WE ARE ABLE TO CHOOSE THE BEST BARIATRIC METABOLIC PROCEDURE FOR YOUR PATIENT
Good long-term results are our marketing toolSuccessful patients make a lot of referralsbull
CHOICE OF PROCEDURE
The MOHAK Guide for Choice of Bariatric Metabolic Surgery Operations
We offer various treatment modalities for obesity The operation is
determined by the profile of the patient and guided by findings from
analysis of the data from our prospectively maintained database
MOHAK TEAM INDORE INDIA
THANK YOU
CHOICE OF PROCEDURE
PharmacotherapyDietingPhysical exerciseBehavioral modificationPsychotherapySurgical intervention
A multidisciplinary approach including Surgical intervention provides the only long term option for treatment of obesity
TREATMENT OPTIONS
CHOICE OF PROCEDURE
ARMAMENTARIUM OF BARIATRIC METABOLIC PROCEDURES
bull The least effective current surgical
operation is many fold more effective
than any known non surgical treatment
SOS
Study
What we have learnt thus far
CHOICE OF PROCEDURE
CHOICE OF PROCEDURE
WHAT WE HAVE LEARNT THUS FAR
No one operation fits the needs of all patients
Choice of Operation
1 We currently have a better understanding of the Disease entity Obesity and the determining factors that affect the treatment of obesity
2 Mechanisms of action of various bariatric metabolic operations
AND
3 We know more about the operations---the relative contra-indications and the short and long-term outcomes of the various procedures
CHOICE OF PROCEDURE
THE DISEASE OBESITY
CHOICE OF PROCEDURE
THE DISEASE OBESITY
Obesity is a multi-system disease
Determining factors in the obese that affect the outcome of operations
Co morbid conditions
Risk factors in surgical treatment of obesity
CHOICE OF PROCEDURE
DETERMINING FACTORS
Genetics Expression of ObesityResponse to surgical treatment
Medical Metabolic syndrome T2DM CAD HO VTE Presence or absence of GERD Liver status and Mental Illness
Patient profile BMI Age GenderSocio-psycho-economic Factors
Smoking Alcohol intake Access to post op care Distance from care provider Cost of the operation-Cost and availability of equipment devices and suppliesAffordability of post operative care-Supplements-educational-financial status
DemographicEnvironmental factorsVegetarianAreas endemic to certain problemsmdashCancer UlcersCultural norms
MECHANISMS OF ACTION OF VARIOUS BARIATRIC METABOLIC OPERATIONS
bull Restrictive Effect Control the reservoir size
bull Neural Stimulation of G-E full sense effectsatiation
bull Patient Compliance Forced behavior modification Motivation fear dyspepsia physical activity dietary habit alteration support group participation and physician contact
bull Malabsorptive Effect Bypassed segment of the GI tract results in mal absorption
bull Dumping Effect High caloric fluid and fatty food intolerance
bull Ghrelin Effect Anorexia
bull Foregut effect GIP PYY and Leptin effects
bull Hindgut effect GLP-I motilityNauseasatiation
bull Microbiota effect alteration of the bacterial flora of the gut alters absorption
bull Bile salts
CHOICE OF PROCEDURE
Currently known mechanisms responsible for the effects of the various bariatric metabolic operations include but not limited to
Outcomes of the various operationsWeight Loss and maintenanceResolution of co-morbid conditions---Contra-indications to the various operations--Complications inherent in the operations----
CHOICE OF PROCEDURE
bull Refluxbull Ulcersbull Nutrient deficienciesbull Protein caloric malnutritionbull DiarrheaSteatorrheabull Food Intolerancebull RingBand Migration
The Operations and Procedures
SURGICAL TREATMENT OPTIONS
A Bariatric Metabolic Surgeon should be able to Perform these three basic procedures and their modifications
Sleeve Gastrectomy Gastric Bypass OAGBMGB
CHOICE OF PROCEDURE
CHOICE OF PROCEDURE
Sleeve Gastrectomy Ring BandedSleeve Gastrectomy
The Ring Stabilizes The Size of The Sleeveand minimizes the disadvantagesSEEVE GASTRECTOMY
1 Relatively simple operation2 No disruption of gastrointestinal tract3 No gastro-intestinal anastomosis4 Nearly regular intestinal absorption 5 Low incidence of dumping syndrome6 0 risk of developing an internal hernia 7 Good weight loss and resolution of
co-morbid conditions almost equal to GBP
Disadvantages-Weight loss ltLGBP-Dilation of sleeve with weight regain and recurrence of co-morbid conditions
-Neo-reflux-Intractable leaks-Torsionstenosis-Porto-mesenteric thrombosis
CHOICE OF PROCEDURE
Sleeve Gastrectomy
Ring BandedSleeve Gastrectomy
06M 1 yr 2yr 3yr 4yr 5yr 6yr
EB
WL
Follow UP
p vs Baseline always lt0001 BSG LSG
Bhandari M Mathur W etal In Print SOARD
CHOICE OF PROCEDURE
THREE YEARS SIX YEARS
THREE YEARS SIX YEARSLess than 50 50-75 above75 Less than 50 50-75 above75
BSG (0) 0 (2) 35 (56) 965 (0) 0 (4) 83 (44) 917
LSG (15)111 (66)474 (53)395 (46)469 (46)469 (9)91
0102030405060708090
100
BSG
LSG
3 YEARSLSG 111BSG 0
FAILURE RATE
6 YEARSLSG 469BSG 0
CHOICE OF PROCEDURE
CHOICE OF PROCEDURE
Bhandari M Mathur W Mishra A MBRSC Course May 2017 Indore India
The Gastric Bypass is the Gold Standard of Bariatric Metabolic Operations
RGBP BGBP
CHOICE OF PROCEDURE
COMPARISON OF BGBP VS STD GBP
Outcome after the operations BGBP STD GBP
Av Initial weight loss 1-3yrs gt77 65-70
Weight loss 4-10 years 70-77 55-65
Resolution of T2DM 80--85 60-80
VomitingSolid Food Intolerance 5-15 lt5
Significant Weight regain 3-7 10-35
Ringband Erosion 0-2 NA
CHOICE OF PROCEDURE
OAGBPMGB
One Anastamosis Gastric BypassMini Gastric Bypass (OAGBMGB)
Simplicity
Repeatability
Minimal Dissection
Reversibility
Exit Strategy
Safety
Minimal Suturing
Short Duration
Short Learning Curve
CHOICE OF PROCEDURE
OAGBSAGBMGB Advantagesbull Easier operation compared to Standard GBPbull Better food tolerancebull More weight loss than standard GBPbull Better weigh Loss Maintenancebull Higher metabolic effect on T2DM and Hyperlipidemiabull Less incidence of internal herniabull More options for revision if needed
Disadvantagesbull Bile reflux gastritis and esophagitisbull Marginal ulcersbull Nutrient deficienciesbull Protein Caloric Malnutrition
Quan Y Huanh A Ye M Efficacy of laproscopic mini gastric bypass for obesity and type 2 diabetes mellitus A systematic review and met-analysis Gastroenterol Res Pract 2015 ID 152852 10155
CHOICE OF PROCEDURE
2015 ndash Review articleVictorzon M et al Scand J Surg 2015 Mar104(1)48-53 Single-anastomosis gastric
bypass better faster and safer
bull The abstracts of 73 articles were reviewed and after removal of case studies duplicates and irrelevant articles 10 articles remained for closer review
bull Several thousand of this operation have been performed for more than 15 years It is claimed to be an easier safer faster and more effective metabolic operation compared to the standard Roux-en-Y gastric bypass The proponents of this operation also claim that this operation is easier to revise and reverse leaving more options compared to the situation after standard bypass in case of failure However there is much controversy surrounding this method mainly concerning the possible harmful and in the long-term even carcinogenic effects of biliopancreaticoduodenal reflux in the gastric pouch
Comment
Several thousands MGBs performed over 15 yrsEasier safer faster amp more effective than
RYGBEasier to revise amp reverse
Controversy regarding carcinogenic effect of BPD reflux
1306
1213
1294
1218
131
1207
114
116
118
12
122
124
126
128
13
132
Before After
BGB LGB MGB
Hemoglobin
RYGB VS Banded RYGB VS OAGBMGB
CHOICE OF PROCEDURE
399
372
394
36
396
352
32
33
34
35
36
37
38
39
4
41
Before After
BGB LGB MGB
Albumin661
644
693
67
685
607
56
58
6
62
64
66
68
7
Before After
BGB LGB MGB
Protein
RYGB VS Banded RYGB VS OAGBMGB
CHOICE OF PROCEDURE
911
87
906
873
909
833
78
8
82
84
86
88
9
92
Before After
BGB LGB MGB
Calcium
CHOICE OF PROCEDURE
RYGB VS Banded RYGB VS OAGBMGB
COMPARISON OF BGBP OAGB VS STD GBP
Outcome after the operations BGBP OAGBP STD GBP
Av Initial weight loss 1-3yrs gt77 gt77 65-70
Weight loss 4-10 years 70-77 70-77 55-65
Resolution of T2DM 80--85 80-90 60-80
VomitingSolid Food Intolerance 5-15 lt5 lt5
Diarrhea and Steatorrhea 1-2A 15-30 NA
Symptomatic Reflux 1-3 3-11 1-3
Marginal Ulcers 3-5 3-5 3-5
Protein Caloric Malnutrition lt1 3-11 lt1
Significant Weight regain 3-10 3-10 10-35
Ringband Erosion 0-1 NA NA
CHOICE OF PROCEDURE
We have enough information currently to enhance the outcome and minimize the risk by matching the operation to the patient
That is the basis forAn Algorithm for Bariatric Metabolic Operations
CHOOSING THE BEST BARIATRIC METABOLIC PROCEDURE FOR THE PATIENT
CHOICE OF PROCEDURE
bull All agesbull With no diabetesbull With low BMI preferably lt40bull With no GERDbull With HO PUDbull With HO or findings of liver diseasebull With Inflammatory bowel diseasebull With dense adhesions from multiple small bowel surgeriesbull Without HO VTEbull In heavy smokers who are not likely to quitbull In gastric cancer endemic areasbull High Risk needing minimal anesthesia and OR timebull High BMI gt 60 as part of a two stage approach
ALGORITHM
LSG BSG
CHOICE OF PROCEDURE
Laparoscopic Sleeve Gastrectomy Or Banded Sleeve Gastrostomy (SGBSD) Indicated for Patients
-All ages-Patients with T2DM lt5years and HbA1-c lt8 C-Peptidegt2 and not on insulin
-Patients with GERD
-ALL BMI ----- -BGBPBMIlt50-- LGBP
Vegetarian (BGBP)
BGBPLGBP
CHOICE OF PROCEDURE
ALGORITHM
Laparoscopic Gastric Bypass(LGBP) or Banded Gastric Bypass(BGBP) Indicated for Patients
bull With Diabetes gt5 years HbA1cgt8 C-Peptide lt2andor on Insulinbull All agesbull All BMI particularly High BMI-gt50bull High risk patients with need for short anesthesia timebull Because it is an easy to perform procedurebull Best tolerated by non Vegetarian
bull GERD Is a contraindicationbull Liver disease is a contraindication
Must be able to follow up patient regularlyPatient must be able to afford the required supplements OAGB
CHOICE OF PROCEDURE
ALGORITHM
OAGBMGB for patients
Sleeve gastrectomy with duodenal bypass(SGDJB) in patients with indication for Gastric Bypass in Gastric Cancer Endemic Areas
As effective as GBPSame weight loss andmetabolic effects as gastric bypass
SG-DJB
CHOICE OF PROCEDURE
ALGORITHM
Sleeve gastrectomy with duodenal bypass(SGDJB) in patients
1Second stage operation for the sleeve gastrectomy
2 Non responders or complications of sleeve gastric bypass or OAGBMGB
BPD-DS SADI SASI SG with enteral bypass
CHOICE OF PROCEDURE
ALGORITHM
BPD-DS SADI SAGI SASI) Indicated for
Areas with high incidence of anemia and very strict vegetarian food habits
CHOICE OF PROCEDURE
ALGORITHM
Sleeve Gastrectomy with gastro-jejunal gastro-ileal or entero-enteral anastomosis
Intra Gastric Balloon ENDOBARRIER
V-BLOC Aspire AssistEndoscopic Plication
For a patient who does not want an intra abdominal gastro-intestinal procedure
CHOICE OF PROCEDURE
Should You Do A Bariatric Metabolic Operation Because That Is What The Patient Wantsrdquo
NOYESmdashIt depends HoweverA bariatric metabolic surgeon should be able to offer the best operation for the patient based on the patientrsquos profile It is good practice to refer the patient to a tertiary center if the surgeon does not offer the operation that meets the patients indication
CHOICE OF PROCEDURE
CHOOSING THE BEST BARIATRIC METABOLIC PROCEDURE FOR THE PATIENT
CHOICE OF PROCEDURE
Case 157 yo Male BMI 57KgM2 T2DM GERD Strict Vegetarian
Algorithm
Gastric bypass-----Preferably Banded gastric bypassmdash------GERD Vegetarian
Not Sleeve because of T2DM GERD and High BMI
Not OAGBMGB because of GERD and probable of protein deficiency
CHOOSING THE BEST BARIATRIC METABOLIC PROCEDURE FOR THE PATIENT
CHOICE OF PROCEDURE
Case 1128 y0 F BMI 42 PCO DUB OSA and HO Migraine headaches
AlgorithmSleeve GastrectomymdashPreferably a Ring banded Sleeve gastrectomy
----No T2DM---No GERDNot Gastric bypass mdash anemia smelly flatus
Not OAGBMGB----Anemia Foul smelling flatus and body odor----Protein deficiency
CHOOSING THE BEST BARIATRIC METABOLIC PROCEDURE FOR THE PATIENT
CHOICE OF PROCEDURE
Case 11137 yo Male BMI 68 OSA OA and a non vegetarian who works at your hospitalReferred by the pulmonologist at your medical Centre
Algorithm
OAGBMGBmdashHigh BMI Non Veg-better food tolerance patient very likely to be followedand to afford the supplements because of proximity to your center
Not sleeve---poor weight loss with sleeve in super obeseNot Banded sleeve---Good weight loss but poor food tolerance since patient is a non vegetarianNot Gastric bypass---Weight loss in super obese have high non response after gastric bypass
and the gastric bypass is technically a more difficult operation than the OAGBNot Banded gastric bypass ndashGood weight loss but a BGBP is a more difficult operation and
the patient will have some food intolerance because of the ring
SURGICAL TREATMENT OPTIONS
At Mohak we perform these standard three operations and their banded modifications
Sleeve Gastrectomy Gastric Bypass OAGBMGB
CHOICE OF PROCEDURE
Evidence based operations performed at MBRSC From 2010 t0 2017---Standardized OperationsLaparoscopic Sleeve Gastrectomybull 90-120 cc Sleevebull 2-5cm from pylorusbull Where a sleeve is indicated but a band is contraindicated or not affordableBanded Sleeve Gastrectomy (BSG) 84 EWL after 60 monthsbull 90-120 cc Sleevebull 2-5cm from pylorusbull Ring 65-75 cmbull At 3-6 cm below GE junctionBanded Gastric bypass (BGBP) 75 EWL 48 monthsbull Create 6mdash7cm long pouchbull 65-75 cm ring at 3-5 cm below GE junction and gt2cm above anastomosisbull Large Gastroenterostomy gt 2cm bull 100cm Roux Limb and 80 cm BP limb for BMIlt50bull 100cm Roux Limb and 150 cm BP limb for BMIgt50Mini-Gastric Bypass (MGB) (OAGB) 79 EWL 60 monthsbull 9-18cm long pouch ~25cm widebull BP Limb length of 180cm BMIlt50Banded Mini-Gastric Bypass(BMGB)(BOAGB)bull 9-18cm long pouch ~25cm widebull Ring 7-75 cmbull BP Limb length of 180cm BMI50
THE MOHAK PROTOCOLStandardized Bariatric and Robotic Surgery Operations
CHOICE OF PROCEDURE
Sleeve Gastrectomy (LSG) or Banded Sleeve Gastrectomy (BSG)bull Non-diabeticsbull No hiatal hernia or GERDbull HO Smokingbull HO alcohol usebull HO PUDbull Abnormal LFTs NASH and early Cirrhosisbull Pts from areas with high incidence of gastric cancer of H pylori infectionbull High risks patients and super obese patients as part of a two-staged operation
Gastric Bypass (LGBP) or Banded Gastric Bypass (BGBP) or Hybrid BGBPMGBbull Have T2DM with HgbA1c lt 8 and duration lt 5 yearsbull Have Hiatal hernia or GERDbull Are Vegetarianbull No nicotine addiction (smoking)bull Have HO Alcohol intake bull Have NASH at surgery-No cirrhosisbull Not likely to come back for follow up andbull Revision operation of Failed Sleeve gastrectomy GBP or MGB
MOHAK ALGORITHM
CHOICE OF PROCEDURE
One Anastomosis Gastric Bypass-Mini-Gastric Bypass (OAGBP-MGB) bull Have T2DM with HgbA1c 8 and durationgt5 yearsbull Have No GERDbull Are Non-vegetarianbull Have poor dentitionbull Most likely to return for follow up at the clinicbull No HO alcohol intakebull No Nicotine addiction (smoking)bull Normal LFTsbull No NASH at surgery or cirrhosisbull Commitment by our program to have 100 follow up of theses patient
Revision Operationbull Sleeve to Banded RY with 100 cm Al limb and 180 cm BP Limbbull MGB to diverted MGB for Reflux Existing BPL and 100cm ALbull MGB to GBP for PCM or reversal to normal anatomy for PCMmdashinterim gastrostomy feedingbull GBP to BGBP with 180cm BP limb for Weight regain or inadequate weight loss BMIlt40bull GBP to BGBP with 300cm common limb for Weight regain or inadequate weight loss BMIgt40
MOHAK ALGORITHM
CHOICE OF PROCEDURE
bull Laparoscopic Gastric Bypass
bull Laparoscopic Sleeve Gastrectomy
bull Divided Mini-Gastric Bypass
bull Biliopancreatic Diversion with DS
bull Single Anastomosis Duodeno-ileostomy
bull Gastric Plication
bull Banded Gastric Plication
bull Endoscopic Gastroplasty
bull Laparoscopic Adjustable Gastric bands
bull Balloon Implantation
bull Ileal interposition
These other operations will be used selectively based on patients needs and the surgeons determination
CHOICE OF PROCEDURE
The MOHAK Guide for Choice of Bariatric Metabolic Surgery Operations
Single Incision Laparoscopic Robotic and Endoscopic approaches are
available at patientsrsquo requests and the discretion of the surgeon
CHOICE OF PROCEDURE
The MOHAK Guide for Choice of Bariatric Metabolic Surgery Operations
Mohak Bariatrics and Robotics Surgery Center Motto
ldquoThe best operation for the patient by a competent surgeon in a well equipped hospital to maximize outcomes with the least amount of risks exposurerdquo
WE ARE ABLE TO CHOOSE THE BEST BARIATRIC METABOLIC PROCEDURE FOR YOUR PATIENT
Good long-term results are our marketing toolSuccessful patients make a lot of referralsbull
CHOICE OF PROCEDURE
The MOHAK Guide for Choice of Bariatric Metabolic Surgery Operations
We offer various treatment modalities for obesity The operation is
determined by the profile of the patient and guided by findings from
analysis of the data from our prospectively maintained database
MOHAK TEAM INDORE INDIA
THANK YOU
CHOICE OF PROCEDURE
ARMAMENTARIUM OF BARIATRIC METABOLIC PROCEDURES
bull The least effective current surgical
operation is many fold more effective
than any known non surgical treatment
SOS
Study
What we have learnt thus far
CHOICE OF PROCEDURE
CHOICE OF PROCEDURE
WHAT WE HAVE LEARNT THUS FAR
No one operation fits the needs of all patients
Choice of Operation
1 We currently have a better understanding of the Disease entity Obesity and the determining factors that affect the treatment of obesity
2 Mechanisms of action of various bariatric metabolic operations
AND
3 We know more about the operations---the relative contra-indications and the short and long-term outcomes of the various procedures
CHOICE OF PROCEDURE
THE DISEASE OBESITY
CHOICE OF PROCEDURE
THE DISEASE OBESITY
Obesity is a multi-system disease
Determining factors in the obese that affect the outcome of operations
Co morbid conditions
Risk factors in surgical treatment of obesity
CHOICE OF PROCEDURE
DETERMINING FACTORS
Genetics Expression of ObesityResponse to surgical treatment
Medical Metabolic syndrome T2DM CAD HO VTE Presence or absence of GERD Liver status and Mental Illness
Patient profile BMI Age GenderSocio-psycho-economic Factors
Smoking Alcohol intake Access to post op care Distance from care provider Cost of the operation-Cost and availability of equipment devices and suppliesAffordability of post operative care-Supplements-educational-financial status
DemographicEnvironmental factorsVegetarianAreas endemic to certain problemsmdashCancer UlcersCultural norms
MECHANISMS OF ACTION OF VARIOUS BARIATRIC METABOLIC OPERATIONS
bull Restrictive Effect Control the reservoir size
bull Neural Stimulation of G-E full sense effectsatiation
bull Patient Compliance Forced behavior modification Motivation fear dyspepsia physical activity dietary habit alteration support group participation and physician contact
bull Malabsorptive Effect Bypassed segment of the GI tract results in mal absorption
bull Dumping Effect High caloric fluid and fatty food intolerance
bull Ghrelin Effect Anorexia
bull Foregut effect GIP PYY and Leptin effects
bull Hindgut effect GLP-I motilityNauseasatiation
bull Microbiota effect alteration of the bacterial flora of the gut alters absorption
bull Bile salts
CHOICE OF PROCEDURE
Currently known mechanisms responsible for the effects of the various bariatric metabolic operations include but not limited to
Outcomes of the various operationsWeight Loss and maintenanceResolution of co-morbid conditions---Contra-indications to the various operations--Complications inherent in the operations----
CHOICE OF PROCEDURE
bull Refluxbull Ulcersbull Nutrient deficienciesbull Protein caloric malnutritionbull DiarrheaSteatorrheabull Food Intolerancebull RingBand Migration
The Operations and Procedures
SURGICAL TREATMENT OPTIONS
A Bariatric Metabolic Surgeon should be able to Perform these three basic procedures and their modifications
Sleeve Gastrectomy Gastric Bypass OAGBMGB
CHOICE OF PROCEDURE
CHOICE OF PROCEDURE
Sleeve Gastrectomy Ring BandedSleeve Gastrectomy
The Ring Stabilizes The Size of The Sleeveand minimizes the disadvantagesSEEVE GASTRECTOMY
1 Relatively simple operation2 No disruption of gastrointestinal tract3 No gastro-intestinal anastomosis4 Nearly regular intestinal absorption 5 Low incidence of dumping syndrome6 0 risk of developing an internal hernia 7 Good weight loss and resolution of
co-morbid conditions almost equal to GBP
Disadvantages-Weight loss ltLGBP-Dilation of sleeve with weight regain and recurrence of co-morbid conditions
-Neo-reflux-Intractable leaks-Torsionstenosis-Porto-mesenteric thrombosis
CHOICE OF PROCEDURE
Sleeve Gastrectomy
Ring BandedSleeve Gastrectomy
06M 1 yr 2yr 3yr 4yr 5yr 6yr
EB
WL
Follow UP
p vs Baseline always lt0001 BSG LSG
Bhandari M Mathur W etal In Print SOARD
CHOICE OF PROCEDURE
THREE YEARS SIX YEARS
THREE YEARS SIX YEARSLess than 50 50-75 above75 Less than 50 50-75 above75
BSG (0) 0 (2) 35 (56) 965 (0) 0 (4) 83 (44) 917
LSG (15)111 (66)474 (53)395 (46)469 (46)469 (9)91
0102030405060708090
100
BSG
LSG
3 YEARSLSG 111BSG 0
FAILURE RATE
6 YEARSLSG 469BSG 0
CHOICE OF PROCEDURE
CHOICE OF PROCEDURE
Bhandari M Mathur W Mishra A MBRSC Course May 2017 Indore India
The Gastric Bypass is the Gold Standard of Bariatric Metabolic Operations
RGBP BGBP
CHOICE OF PROCEDURE
COMPARISON OF BGBP VS STD GBP
Outcome after the operations BGBP STD GBP
Av Initial weight loss 1-3yrs gt77 65-70
Weight loss 4-10 years 70-77 55-65
Resolution of T2DM 80--85 60-80
VomitingSolid Food Intolerance 5-15 lt5
Significant Weight regain 3-7 10-35
Ringband Erosion 0-2 NA
CHOICE OF PROCEDURE
OAGBPMGB
One Anastamosis Gastric BypassMini Gastric Bypass (OAGBMGB)
Simplicity
Repeatability
Minimal Dissection
Reversibility
Exit Strategy
Safety
Minimal Suturing
Short Duration
Short Learning Curve
CHOICE OF PROCEDURE
OAGBSAGBMGB Advantagesbull Easier operation compared to Standard GBPbull Better food tolerancebull More weight loss than standard GBPbull Better weigh Loss Maintenancebull Higher metabolic effect on T2DM and Hyperlipidemiabull Less incidence of internal herniabull More options for revision if needed
Disadvantagesbull Bile reflux gastritis and esophagitisbull Marginal ulcersbull Nutrient deficienciesbull Protein Caloric Malnutrition
Quan Y Huanh A Ye M Efficacy of laproscopic mini gastric bypass for obesity and type 2 diabetes mellitus A systematic review and met-analysis Gastroenterol Res Pract 2015 ID 152852 10155
CHOICE OF PROCEDURE
2015 ndash Review articleVictorzon M et al Scand J Surg 2015 Mar104(1)48-53 Single-anastomosis gastric
bypass better faster and safer
bull The abstracts of 73 articles were reviewed and after removal of case studies duplicates and irrelevant articles 10 articles remained for closer review
bull Several thousand of this operation have been performed for more than 15 years It is claimed to be an easier safer faster and more effective metabolic operation compared to the standard Roux-en-Y gastric bypass The proponents of this operation also claim that this operation is easier to revise and reverse leaving more options compared to the situation after standard bypass in case of failure However there is much controversy surrounding this method mainly concerning the possible harmful and in the long-term even carcinogenic effects of biliopancreaticoduodenal reflux in the gastric pouch
Comment
Several thousands MGBs performed over 15 yrsEasier safer faster amp more effective than
RYGBEasier to revise amp reverse
Controversy regarding carcinogenic effect of BPD reflux
1306
1213
1294
1218
131
1207
114
116
118
12
122
124
126
128
13
132
Before After
BGB LGB MGB
Hemoglobin
RYGB VS Banded RYGB VS OAGBMGB
CHOICE OF PROCEDURE
399
372
394
36
396
352
32
33
34
35
36
37
38
39
4
41
Before After
BGB LGB MGB
Albumin661
644
693
67
685
607
56
58
6
62
64
66
68
7
Before After
BGB LGB MGB
Protein
RYGB VS Banded RYGB VS OAGBMGB
CHOICE OF PROCEDURE
911
87
906
873
909
833
78
8
82
84
86
88
9
92
Before After
BGB LGB MGB
Calcium
CHOICE OF PROCEDURE
RYGB VS Banded RYGB VS OAGBMGB
COMPARISON OF BGBP OAGB VS STD GBP
Outcome after the operations BGBP OAGBP STD GBP
Av Initial weight loss 1-3yrs gt77 gt77 65-70
Weight loss 4-10 years 70-77 70-77 55-65
Resolution of T2DM 80--85 80-90 60-80
VomitingSolid Food Intolerance 5-15 lt5 lt5
Diarrhea and Steatorrhea 1-2A 15-30 NA
Symptomatic Reflux 1-3 3-11 1-3
Marginal Ulcers 3-5 3-5 3-5
Protein Caloric Malnutrition lt1 3-11 lt1
Significant Weight regain 3-10 3-10 10-35
Ringband Erosion 0-1 NA NA
CHOICE OF PROCEDURE
We have enough information currently to enhance the outcome and minimize the risk by matching the operation to the patient
That is the basis forAn Algorithm for Bariatric Metabolic Operations
CHOOSING THE BEST BARIATRIC METABOLIC PROCEDURE FOR THE PATIENT
CHOICE OF PROCEDURE
bull All agesbull With no diabetesbull With low BMI preferably lt40bull With no GERDbull With HO PUDbull With HO or findings of liver diseasebull With Inflammatory bowel diseasebull With dense adhesions from multiple small bowel surgeriesbull Without HO VTEbull In heavy smokers who are not likely to quitbull In gastric cancer endemic areasbull High Risk needing minimal anesthesia and OR timebull High BMI gt 60 as part of a two stage approach
ALGORITHM
LSG BSG
CHOICE OF PROCEDURE
Laparoscopic Sleeve Gastrectomy Or Banded Sleeve Gastrostomy (SGBSD) Indicated for Patients
-All ages-Patients with T2DM lt5years and HbA1-c lt8 C-Peptidegt2 and not on insulin
-Patients with GERD
-ALL BMI ----- -BGBPBMIlt50-- LGBP
Vegetarian (BGBP)
BGBPLGBP
CHOICE OF PROCEDURE
ALGORITHM
Laparoscopic Gastric Bypass(LGBP) or Banded Gastric Bypass(BGBP) Indicated for Patients
bull With Diabetes gt5 years HbA1cgt8 C-Peptide lt2andor on Insulinbull All agesbull All BMI particularly High BMI-gt50bull High risk patients with need for short anesthesia timebull Because it is an easy to perform procedurebull Best tolerated by non Vegetarian
bull GERD Is a contraindicationbull Liver disease is a contraindication
Must be able to follow up patient regularlyPatient must be able to afford the required supplements OAGB
CHOICE OF PROCEDURE
ALGORITHM
OAGBMGB for patients
Sleeve gastrectomy with duodenal bypass(SGDJB) in patients with indication for Gastric Bypass in Gastric Cancer Endemic Areas
As effective as GBPSame weight loss andmetabolic effects as gastric bypass
SG-DJB
CHOICE OF PROCEDURE
ALGORITHM
Sleeve gastrectomy with duodenal bypass(SGDJB) in patients
1Second stage operation for the sleeve gastrectomy
2 Non responders or complications of sleeve gastric bypass or OAGBMGB
BPD-DS SADI SASI SG with enteral bypass
CHOICE OF PROCEDURE
ALGORITHM
BPD-DS SADI SAGI SASI) Indicated for
Areas with high incidence of anemia and very strict vegetarian food habits
CHOICE OF PROCEDURE
ALGORITHM
Sleeve Gastrectomy with gastro-jejunal gastro-ileal or entero-enteral anastomosis
Intra Gastric Balloon ENDOBARRIER
V-BLOC Aspire AssistEndoscopic Plication
For a patient who does not want an intra abdominal gastro-intestinal procedure
CHOICE OF PROCEDURE
Should You Do A Bariatric Metabolic Operation Because That Is What The Patient Wantsrdquo
NOYESmdashIt depends HoweverA bariatric metabolic surgeon should be able to offer the best operation for the patient based on the patientrsquos profile It is good practice to refer the patient to a tertiary center if the surgeon does not offer the operation that meets the patients indication
CHOICE OF PROCEDURE
CHOOSING THE BEST BARIATRIC METABOLIC PROCEDURE FOR THE PATIENT
CHOICE OF PROCEDURE
Case 157 yo Male BMI 57KgM2 T2DM GERD Strict Vegetarian
Algorithm
Gastric bypass-----Preferably Banded gastric bypassmdash------GERD Vegetarian
Not Sleeve because of T2DM GERD and High BMI
Not OAGBMGB because of GERD and probable of protein deficiency
CHOOSING THE BEST BARIATRIC METABOLIC PROCEDURE FOR THE PATIENT
CHOICE OF PROCEDURE
Case 1128 y0 F BMI 42 PCO DUB OSA and HO Migraine headaches
AlgorithmSleeve GastrectomymdashPreferably a Ring banded Sleeve gastrectomy
----No T2DM---No GERDNot Gastric bypass mdash anemia smelly flatus
Not OAGBMGB----Anemia Foul smelling flatus and body odor----Protein deficiency
CHOOSING THE BEST BARIATRIC METABOLIC PROCEDURE FOR THE PATIENT
CHOICE OF PROCEDURE
Case 11137 yo Male BMI 68 OSA OA and a non vegetarian who works at your hospitalReferred by the pulmonologist at your medical Centre
Algorithm
OAGBMGBmdashHigh BMI Non Veg-better food tolerance patient very likely to be followedand to afford the supplements because of proximity to your center
Not sleeve---poor weight loss with sleeve in super obeseNot Banded sleeve---Good weight loss but poor food tolerance since patient is a non vegetarianNot Gastric bypass---Weight loss in super obese have high non response after gastric bypass
and the gastric bypass is technically a more difficult operation than the OAGBNot Banded gastric bypass ndashGood weight loss but a BGBP is a more difficult operation and
the patient will have some food intolerance because of the ring
SURGICAL TREATMENT OPTIONS
At Mohak we perform these standard three operations and their banded modifications
Sleeve Gastrectomy Gastric Bypass OAGBMGB
CHOICE OF PROCEDURE
Evidence based operations performed at MBRSC From 2010 t0 2017---Standardized OperationsLaparoscopic Sleeve Gastrectomybull 90-120 cc Sleevebull 2-5cm from pylorusbull Where a sleeve is indicated but a band is contraindicated or not affordableBanded Sleeve Gastrectomy (BSG) 84 EWL after 60 monthsbull 90-120 cc Sleevebull 2-5cm from pylorusbull Ring 65-75 cmbull At 3-6 cm below GE junctionBanded Gastric bypass (BGBP) 75 EWL 48 monthsbull Create 6mdash7cm long pouchbull 65-75 cm ring at 3-5 cm below GE junction and gt2cm above anastomosisbull Large Gastroenterostomy gt 2cm bull 100cm Roux Limb and 80 cm BP limb for BMIlt50bull 100cm Roux Limb and 150 cm BP limb for BMIgt50Mini-Gastric Bypass (MGB) (OAGB) 79 EWL 60 monthsbull 9-18cm long pouch ~25cm widebull BP Limb length of 180cm BMIlt50Banded Mini-Gastric Bypass(BMGB)(BOAGB)bull 9-18cm long pouch ~25cm widebull Ring 7-75 cmbull BP Limb length of 180cm BMI50
THE MOHAK PROTOCOLStandardized Bariatric and Robotic Surgery Operations
CHOICE OF PROCEDURE
Sleeve Gastrectomy (LSG) or Banded Sleeve Gastrectomy (BSG)bull Non-diabeticsbull No hiatal hernia or GERDbull HO Smokingbull HO alcohol usebull HO PUDbull Abnormal LFTs NASH and early Cirrhosisbull Pts from areas with high incidence of gastric cancer of H pylori infectionbull High risks patients and super obese patients as part of a two-staged operation
Gastric Bypass (LGBP) or Banded Gastric Bypass (BGBP) or Hybrid BGBPMGBbull Have T2DM with HgbA1c lt 8 and duration lt 5 yearsbull Have Hiatal hernia or GERDbull Are Vegetarianbull No nicotine addiction (smoking)bull Have HO Alcohol intake bull Have NASH at surgery-No cirrhosisbull Not likely to come back for follow up andbull Revision operation of Failed Sleeve gastrectomy GBP or MGB
MOHAK ALGORITHM
CHOICE OF PROCEDURE
One Anastomosis Gastric Bypass-Mini-Gastric Bypass (OAGBP-MGB) bull Have T2DM with HgbA1c 8 and durationgt5 yearsbull Have No GERDbull Are Non-vegetarianbull Have poor dentitionbull Most likely to return for follow up at the clinicbull No HO alcohol intakebull No Nicotine addiction (smoking)bull Normal LFTsbull No NASH at surgery or cirrhosisbull Commitment by our program to have 100 follow up of theses patient
Revision Operationbull Sleeve to Banded RY with 100 cm Al limb and 180 cm BP Limbbull MGB to diverted MGB for Reflux Existing BPL and 100cm ALbull MGB to GBP for PCM or reversal to normal anatomy for PCMmdashinterim gastrostomy feedingbull GBP to BGBP with 180cm BP limb for Weight regain or inadequate weight loss BMIlt40bull GBP to BGBP with 300cm common limb for Weight regain or inadequate weight loss BMIgt40
MOHAK ALGORITHM
CHOICE OF PROCEDURE
bull Laparoscopic Gastric Bypass
bull Laparoscopic Sleeve Gastrectomy
bull Divided Mini-Gastric Bypass
bull Biliopancreatic Diversion with DS
bull Single Anastomosis Duodeno-ileostomy
bull Gastric Plication
bull Banded Gastric Plication
bull Endoscopic Gastroplasty
bull Laparoscopic Adjustable Gastric bands
bull Balloon Implantation
bull Ileal interposition
These other operations will be used selectively based on patients needs and the surgeons determination
CHOICE OF PROCEDURE
The MOHAK Guide for Choice of Bariatric Metabolic Surgery Operations
Single Incision Laparoscopic Robotic and Endoscopic approaches are
available at patientsrsquo requests and the discretion of the surgeon
CHOICE OF PROCEDURE
The MOHAK Guide for Choice of Bariatric Metabolic Surgery Operations
Mohak Bariatrics and Robotics Surgery Center Motto
ldquoThe best operation for the patient by a competent surgeon in a well equipped hospital to maximize outcomes with the least amount of risks exposurerdquo
WE ARE ABLE TO CHOOSE THE BEST BARIATRIC METABOLIC PROCEDURE FOR YOUR PATIENT
Good long-term results are our marketing toolSuccessful patients make a lot of referralsbull
CHOICE OF PROCEDURE
The MOHAK Guide for Choice of Bariatric Metabolic Surgery Operations
We offer various treatment modalities for obesity The operation is
determined by the profile of the patient and guided by findings from
analysis of the data from our prospectively maintained database
MOHAK TEAM INDORE INDIA
THANK YOU
bull The least effective current surgical
operation is many fold more effective
than any known non surgical treatment
SOS
Study
What we have learnt thus far
CHOICE OF PROCEDURE
CHOICE OF PROCEDURE
WHAT WE HAVE LEARNT THUS FAR
No one operation fits the needs of all patients
Choice of Operation
1 We currently have a better understanding of the Disease entity Obesity and the determining factors that affect the treatment of obesity
2 Mechanisms of action of various bariatric metabolic operations
AND
3 We know more about the operations---the relative contra-indications and the short and long-term outcomes of the various procedures
CHOICE OF PROCEDURE
THE DISEASE OBESITY
CHOICE OF PROCEDURE
THE DISEASE OBESITY
Obesity is a multi-system disease
Determining factors in the obese that affect the outcome of operations
Co morbid conditions
Risk factors in surgical treatment of obesity
CHOICE OF PROCEDURE
DETERMINING FACTORS
Genetics Expression of ObesityResponse to surgical treatment
Medical Metabolic syndrome T2DM CAD HO VTE Presence or absence of GERD Liver status and Mental Illness
Patient profile BMI Age GenderSocio-psycho-economic Factors
Smoking Alcohol intake Access to post op care Distance from care provider Cost of the operation-Cost and availability of equipment devices and suppliesAffordability of post operative care-Supplements-educational-financial status
DemographicEnvironmental factorsVegetarianAreas endemic to certain problemsmdashCancer UlcersCultural norms
MECHANISMS OF ACTION OF VARIOUS BARIATRIC METABOLIC OPERATIONS
bull Restrictive Effect Control the reservoir size
bull Neural Stimulation of G-E full sense effectsatiation
bull Patient Compliance Forced behavior modification Motivation fear dyspepsia physical activity dietary habit alteration support group participation and physician contact
bull Malabsorptive Effect Bypassed segment of the GI tract results in mal absorption
bull Dumping Effect High caloric fluid and fatty food intolerance
bull Ghrelin Effect Anorexia
bull Foregut effect GIP PYY and Leptin effects
bull Hindgut effect GLP-I motilityNauseasatiation
bull Microbiota effect alteration of the bacterial flora of the gut alters absorption
bull Bile salts
CHOICE OF PROCEDURE
Currently known mechanisms responsible for the effects of the various bariatric metabolic operations include but not limited to
Outcomes of the various operationsWeight Loss and maintenanceResolution of co-morbid conditions---Contra-indications to the various operations--Complications inherent in the operations----
CHOICE OF PROCEDURE
bull Refluxbull Ulcersbull Nutrient deficienciesbull Protein caloric malnutritionbull DiarrheaSteatorrheabull Food Intolerancebull RingBand Migration
The Operations and Procedures
SURGICAL TREATMENT OPTIONS
A Bariatric Metabolic Surgeon should be able to Perform these three basic procedures and their modifications
Sleeve Gastrectomy Gastric Bypass OAGBMGB
CHOICE OF PROCEDURE
CHOICE OF PROCEDURE
Sleeve Gastrectomy Ring BandedSleeve Gastrectomy
The Ring Stabilizes The Size of The Sleeveand minimizes the disadvantagesSEEVE GASTRECTOMY
1 Relatively simple operation2 No disruption of gastrointestinal tract3 No gastro-intestinal anastomosis4 Nearly regular intestinal absorption 5 Low incidence of dumping syndrome6 0 risk of developing an internal hernia 7 Good weight loss and resolution of
co-morbid conditions almost equal to GBP
Disadvantages-Weight loss ltLGBP-Dilation of sleeve with weight regain and recurrence of co-morbid conditions
-Neo-reflux-Intractable leaks-Torsionstenosis-Porto-mesenteric thrombosis
CHOICE OF PROCEDURE
Sleeve Gastrectomy
Ring BandedSleeve Gastrectomy
06M 1 yr 2yr 3yr 4yr 5yr 6yr
EB
WL
Follow UP
p vs Baseline always lt0001 BSG LSG
Bhandari M Mathur W etal In Print SOARD
CHOICE OF PROCEDURE
THREE YEARS SIX YEARS
THREE YEARS SIX YEARSLess than 50 50-75 above75 Less than 50 50-75 above75
BSG (0) 0 (2) 35 (56) 965 (0) 0 (4) 83 (44) 917
LSG (15)111 (66)474 (53)395 (46)469 (46)469 (9)91
0102030405060708090
100
BSG
LSG
3 YEARSLSG 111BSG 0
FAILURE RATE
6 YEARSLSG 469BSG 0
CHOICE OF PROCEDURE
CHOICE OF PROCEDURE
Bhandari M Mathur W Mishra A MBRSC Course May 2017 Indore India
The Gastric Bypass is the Gold Standard of Bariatric Metabolic Operations
RGBP BGBP
CHOICE OF PROCEDURE
COMPARISON OF BGBP VS STD GBP
Outcome after the operations BGBP STD GBP
Av Initial weight loss 1-3yrs gt77 65-70
Weight loss 4-10 years 70-77 55-65
Resolution of T2DM 80--85 60-80
VomitingSolid Food Intolerance 5-15 lt5
Significant Weight regain 3-7 10-35
Ringband Erosion 0-2 NA
CHOICE OF PROCEDURE
OAGBPMGB
One Anastamosis Gastric BypassMini Gastric Bypass (OAGBMGB)
Simplicity
Repeatability
Minimal Dissection
Reversibility
Exit Strategy
Safety
Minimal Suturing
Short Duration
Short Learning Curve
CHOICE OF PROCEDURE
OAGBSAGBMGB Advantagesbull Easier operation compared to Standard GBPbull Better food tolerancebull More weight loss than standard GBPbull Better weigh Loss Maintenancebull Higher metabolic effect on T2DM and Hyperlipidemiabull Less incidence of internal herniabull More options for revision if needed
Disadvantagesbull Bile reflux gastritis and esophagitisbull Marginal ulcersbull Nutrient deficienciesbull Protein Caloric Malnutrition
Quan Y Huanh A Ye M Efficacy of laproscopic mini gastric bypass for obesity and type 2 diabetes mellitus A systematic review and met-analysis Gastroenterol Res Pract 2015 ID 152852 10155
CHOICE OF PROCEDURE
2015 ndash Review articleVictorzon M et al Scand J Surg 2015 Mar104(1)48-53 Single-anastomosis gastric
bypass better faster and safer
bull The abstracts of 73 articles were reviewed and after removal of case studies duplicates and irrelevant articles 10 articles remained for closer review
bull Several thousand of this operation have been performed for more than 15 years It is claimed to be an easier safer faster and more effective metabolic operation compared to the standard Roux-en-Y gastric bypass The proponents of this operation also claim that this operation is easier to revise and reverse leaving more options compared to the situation after standard bypass in case of failure However there is much controversy surrounding this method mainly concerning the possible harmful and in the long-term even carcinogenic effects of biliopancreaticoduodenal reflux in the gastric pouch
Comment
Several thousands MGBs performed over 15 yrsEasier safer faster amp more effective than
RYGBEasier to revise amp reverse
Controversy regarding carcinogenic effect of BPD reflux
1306
1213
1294
1218
131
1207
114
116
118
12
122
124
126
128
13
132
Before After
BGB LGB MGB
Hemoglobin
RYGB VS Banded RYGB VS OAGBMGB
CHOICE OF PROCEDURE
399
372
394
36
396
352
32
33
34
35
36
37
38
39
4
41
Before After
BGB LGB MGB
Albumin661
644
693
67
685
607
56
58
6
62
64
66
68
7
Before After
BGB LGB MGB
Protein
RYGB VS Banded RYGB VS OAGBMGB
CHOICE OF PROCEDURE
911
87
906
873
909
833
78
8
82
84
86
88
9
92
Before After
BGB LGB MGB
Calcium
CHOICE OF PROCEDURE
RYGB VS Banded RYGB VS OAGBMGB
COMPARISON OF BGBP OAGB VS STD GBP
Outcome after the operations BGBP OAGBP STD GBP
Av Initial weight loss 1-3yrs gt77 gt77 65-70
Weight loss 4-10 years 70-77 70-77 55-65
Resolution of T2DM 80--85 80-90 60-80
VomitingSolid Food Intolerance 5-15 lt5 lt5
Diarrhea and Steatorrhea 1-2A 15-30 NA
Symptomatic Reflux 1-3 3-11 1-3
Marginal Ulcers 3-5 3-5 3-5
Protein Caloric Malnutrition lt1 3-11 lt1
Significant Weight regain 3-10 3-10 10-35
Ringband Erosion 0-1 NA NA
CHOICE OF PROCEDURE
We have enough information currently to enhance the outcome and minimize the risk by matching the operation to the patient
That is the basis forAn Algorithm for Bariatric Metabolic Operations
CHOOSING THE BEST BARIATRIC METABOLIC PROCEDURE FOR THE PATIENT
CHOICE OF PROCEDURE
bull All agesbull With no diabetesbull With low BMI preferably lt40bull With no GERDbull With HO PUDbull With HO or findings of liver diseasebull With Inflammatory bowel diseasebull With dense adhesions from multiple small bowel surgeriesbull Without HO VTEbull In heavy smokers who are not likely to quitbull In gastric cancer endemic areasbull High Risk needing minimal anesthesia and OR timebull High BMI gt 60 as part of a two stage approach
ALGORITHM
LSG BSG
CHOICE OF PROCEDURE
Laparoscopic Sleeve Gastrectomy Or Banded Sleeve Gastrostomy (SGBSD) Indicated for Patients
-All ages-Patients with T2DM lt5years and HbA1-c lt8 C-Peptidegt2 and not on insulin
-Patients with GERD
-ALL BMI ----- -BGBPBMIlt50-- LGBP
Vegetarian (BGBP)
BGBPLGBP
CHOICE OF PROCEDURE
ALGORITHM
Laparoscopic Gastric Bypass(LGBP) or Banded Gastric Bypass(BGBP) Indicated for Patients
bull With Diabetes gt5 years HbA1cgt8 C-Peptide lt2andor on Insulinbull All agesbull All BMI particularly High BMI-gt50bull High risk patients with need for short anesthesia timebull Because it is an easy to perform procedurebull Best tolerated by non Vegetarian
bull GERD Is a contraindicationbull Liver disease is a contraindication
Must be able to follow up patient regularlyPatient must be able to afford the required supplements OAGB
CHOICE OF PROCEDURE
ALGORITHM
OAGBMGB for patients
Sleeve gastrectomy with duodenal bypass(SGDJB) in patients with indication for Gastric Bypass in Gastric Cancer Endemic Areas
As effective as GBPSame weight loss andmetabolic effects as gastric bypass
SG-DJB
CHOICE OF PROCEDURE
ALGORITHM
Sleeve gastrectomy with duodenal bypass(SGDJB) in patients
1Second stage operation for the sleeve gastrectomy
2 Non responders or complications of sleeve gastric bypass or OAGBMGB
BPD-DS SADI SASI SG with enteral bypass
CHOICE OF PROCEDURE
ALGORITHM
BPD-DS SADI SAGI SASI) Indicated for
Areas with high incidence of anemia and very strict vegetarian food habits
CHOICE OF PROCEDURE
ALGORITHM
Sleeve Gastrectomy with gastro-jejunal gastro-ileal or entero-enteral anastomosis
Intra Gastric Balloon ENDOBARRIER
V-BLOC Aspire AssistEndoscopic Plication
For a patient who does not want an intra abdominal gastro-intestinal procedure
CHOICE OF PROCEDURE
Should You Do A Bariatric Metabolic Operation Because That Is What The Patient Wantsrdquo
NOYESmdashIt depends HoweverA bariatric metabolic surgeon should be able to offer the best operation for the patient based on the patientrsquos profile It is good practice to refer the patient to a tertiary center if the surgeon does not offer the operation that meets the patients indication
CHOICE OF PROCEDURE
CHOOSING THE BEST BARIATRIC METABOLIC PROCEDURE FOR THE PATIENT
CHOICE OF PROCEDURE
Case 157 yo Male BMI 57KgM2 T2DM GERD Strict Vegetarian
Algorithm
Gastric bypass-----Preferably Banded gastric bypassmdash------GERD Vegetarian
Not Sleeve because of T2DM GERD and High BMI
Not OAGBMGB because of GERD and probable of protein deficiency
CHOOSING THE BEST BARIATRIC METABOLIC PROCEDURE FOR THE PATIENT
CHOICE OF PROCEDURE
Case 1128 y0 F BMI 42 PCO DUB OSA and HO Migraine headaches
AlgorithmSleeve GastrectomymdashPreferably a Ring banded Sleeve gastrectomy
----No T2DM---No GERDNot Gastric bypass mdash anemia smelly flatus
Not OAGBMGB----Anemia Foul smelling flatus and body odor----Protein deficiency
CHOOSING THE BEST BARIATRIC METABOLIC PROCEDURE FOR THE PATIENT
CHOICE OF PROCEDURE
Case 11137 yo Male BMI 68 OSA OA and a non vegetarian who works at your hospitalReferred by the pulmonologist at your medical Centre
Algorithm
OAGBMGBmdashHigh BMI Non Veg-better food tolerance patient very likely to be followedand to afford the supplements because of proximity to your center
Not sleeve---poor weight loss with sleeve in super obeseNot Banded sleeve---Good weight loss but poor food tolerance since patient is a non vegetarianNot Gastric bypass---Weight loss in super obese have high non response after gastric bypass
and the gastric bypass is technically a more difficult operation than the OAGBNot Banded gastric bypass ndashGood weight loss but a BGBP is a more difficult operation and
the patient will have some food intolerance because of the ring
SURGICAL TREATMENT OPTIONS
At Mohak we perform these standard three operations and their banded modifications
Sleeve Gastrectomy Gastric Bypass OAGBMGB
CHOICE OF PROCEDURE
Evidence based operations performed at MBRSC From 2010 t0 2017---Standardized OperationsLaparoscopic Sleeve Gastrectomybull 90-120 cc Sleevebull 2-5cm from pylorusbull Where a sleeve is indicated but a band is contraindicated or not affordableBanded Sleeve Gastrectomy (BSG) 84 EWL after 60 monthsbull 90-120 cc Sleevebull 2-5cm from pylorusbull Ring 65-75 cmbull At 3-6 cm below GE junctionBanded Gastric bypass (BGBP) 75 EWL 48 monthsbull Create 6mdash7cm long pouchbull 65-75 cm ring at 3-5 cm below GE junction and gt2cm above anastomosisbull Large Gastroenterostomy gt 2cm bull 100cm Roux Limb and 80 cm BP limb for BMIlt50bull 100cm Roux Limb and 150 cm BP limb for BMIgt50Mini-Gastric Bypass (MGB) (OAGB) 79 EWL 60 monthsbull 9-18cm long pouch ~25cm widebull BP Limb length of 180cm BMIlt50Banded Mini-Gastric Bypass(BMGB)(BOAGB)bull 9-18cm long pouch ~25cm widebull Ring 7-75 cmbull BP Limb length of 180cm BMI50
THE MOHAK PROTOCOLStandardized Bariatric and Robotic Surgery Operations
CHOICE OF PROCEDURE
Sleeve Gastrectomy (LSG) or Banded Sleeve Gastrectomy (BSG)bull Non-diabeticsbull No hiatal hernia or GERDbull HO Smokingbull HO alcohol usebull HO PUDbull Abnormal LFTs NASH and early Cirrhosisbull Pts from areas with high incidence of gastric cancer of H pylori infectionbull High risks patients and super obese patients as part of a two-staged operation
Gastric Bypass (LGBP) or Banded Gastric Bypass (BGBP) or Hybrid BGBPMGBbull Have T2DM with HgbA1c lt 8 and duration lt 5 yearsbull Have Hiatal hernia or GERDbull Are Vegetarianbull No nicotine addiction (smoking)bull Have HO Alcohol intake bull Have NASH at surgery-No cirrhosisbull Not likely to come back for follow up andbull Revision operation of Failed Sleeve gastrectomy GBP or MGB
MOHAK ALGORITHM
CHOICE OF PROCEDURE
One Anastomosis Gastric Bypass-Mini-Gastric Bypass (OAGBP-MGB) bull Have T2DM with HgbA1c 8 and durationgt5 yearsbull Have No GERDbull Are Non-vegetarianbull Have poor dentitionbull Most likely to return for follow up at the clinicbull No HO alcohol intakebull No Nicotine addiction (smoking)bull Normal LFTsbull No NASH at surgery or cirrhosisbull Commitment by our program to have 100 follow up of theses patient
Revision Operationbull Sleeve to Banded RY with 100 cm Al limb and 180 cm BP Limbbull MGB to diverted MGB for Reflux Existing BPL and 100cm ALbull MGB to GBP for PCM or reversal to normal anatomy for PCMmdashinterim gastrostomy feedingbull GBP to BGBP with 180cm BP limb for Weight regain or inadequate weight loss BMIlt40bull GBP to BGBP with 300cm common limb for Weight regain or inadequate weight loss BMIgt40
MOHAK ALGORITHM
CHOICE OF PROCEDURE
bull Laparoscopic Gastric Bypass
bull Laparoscopic Sleeve Gastrectomy
bull Divided Mini-Gastric Bypass
bull Biliopancreatic Diversion with DS
bull Single Anastomosis Duodeno-ileostomy
bull Gastric Plication
bull Banded Gastric Plication
bull Endoscopic Gastroplasty
bull Laparoscopic Adjustable Gastric bands
bull Balloon Implantation
bull Ileal interposition
These other operations will be used selectively based on patients needs and the surgeons determination
CHOICE OF PROCEDURE
The MOHAK Guide for Choice of Bariatric Metabolic Surgery Operations
Single Incision Laparoscopic Robotic and Endoscopic approaches are
available at patientsrsquo requests and the discretion of the surgeon
CHOICE OF PROCEDURE
The MOHAK Guide for Choice of Bariatric Metabolic Surgery Operations
Mohak Bariatrics and Robotics Surgery Center Motto
ldquoThe best operation for the patient by a competent surgeon in a well equipped hospital to maximize outcomes with the least amount of risks exposurerdquo
WE ARE ABLE TO CHOOSE THE BEST BARIATRIC METABOLIC PROCEDURE FOR YOUR PATIENT
Good long-term results are our marketing toolSuccessful patients make a lot of referralsbull
CHOICE OF PROCEDURE
The MOHAK Guide for Choice of Bariatric Metabolic Surgery Operations
We offer various treatment modalities for obesity The operation is
determined by the profile of the patient and guided by findings from
analysis of the data from our prospectively maintained database
MOHAK TEAM INDORE INDIA
THANK YOU
CHOICE OF PROCEDURE
WHAT WE HAVE LEARNT THUS FAR
No one operation fits the needs of all patients
Choice of Operation
1 We currently have a better understanding of the Disease entity Obesity and the determining factors that affect the treatment of obesity
2 Mechanisms of action of various bariatric metabolic operations
AND
3 We know more about the operations---the relative contra-indications and the short and long-term outcomes of the various procedures
CHOICE OF PROCEDURE
THE DISEASE OBESITY
CHOICE OF PROCEDURE
THE DISEASE OBESITY
Obesity is a multi-system disease
Determining factors in the obese that affect the outcome of operations
Co morbid conditions
Risk factors in surgical treatment of obesity
CHOICE OF PROCEDURE
DETERMINING FACTORS
Genetics Expression of ObesityResponse to surgical treatment
Medical Metabolic syndrome T2DM CAD HO VTE Presence or absence of GERD Liver status and Mental Illness
Patient profile BMI Age GenderSocio-psycho-economic Factors
Smoking Alcohol intake Access to post op care Distance from care provider Cost of the operation-Cost and availability of equipment devices and suppliesAffordability of post operative care-Supplements-educational-financial status
DemographicEnvironmental factorsVegetarianAreas endemic to certain problemsmdashCancer UlcersCultural norms
MECHANISMS OF ACTION OF VARIOUS BARIATRIC METABOLIC OPERATIONS
bull Restrictive Effect Control the reservoir size
bull Neural Stimulation of G-E full sense effectsatiation
bull Patient Compliance Forced behavior modification Motivation fear dyspepsia physical activity dietary habit alteration support group participation and physician contact
bull Malabsorptive Effect Bypassed segment of the GI tract results in mal absorption
bull Dumping Effect High caloric fluid and fatty food intolerance
bull Ghrelin Effect Anorexia
bull Foregut effect GIP PYY and Leptin effects
bull Hindgut effect GLP-I motilityNauseasatiation
bull Microbiota effect alteration of the bacterial flora of the gut alters absorption
bull Bile salts
CHOICE OF PROCEDURE
Currently known mechanisms responsible for the effects of the various bariatric metabolic operations include but not limited to
Outcomes of the various operationsWeight Loss and maintenanceResolution of co-morbid conditions---Contra-indications to the various operations--Complications inherent in the operations----
CHOICE OF PROCEDURE
bull Refluxbull Ulcersbull Nutrient deficienciesbull Protein caloric malnutritionbull DiarrheaSteatorrheabull Food Intolerancebull RingBand Migration
The Operations and Procedures
SURGICAL TREATMENT OPTIONS
A Bariatric Metabolic Surgeon should be able to Perform these three basic procedures and their modifications
Sleeve Gastrectomy Gastric Bypass OAGBMGB
CHOICE OF PROCEDURE
CHOICE OF PROCEDURE
Sleeve Gastrectomy Ring BandedSleeve Gastrectomy
The Ring Stabilizes The Size of The Sleeveand minimizes the disadvantagesSEEVE GASTRECTOMY
1 Relatively simple operation2 No disruption of gastrointestinal tract3 No gastro-intestinal anastomosis4 Nearly regular intestinal absorption 5 Low incidence of dumping syndrome6 0 risk of developing an internal hernia 7 Good weight loss and resolution of
co-morbid conditions almost equal to GBP
Disadvantages-Weight loss ltLGBP-Dilation of sleeve with weight regain and recurrence of co-morbid conditions
-Neo-reflux-Intractable leaks-Torsionstenosis-Porto-mesenteric thrombosis
CHOICE OF PROCEDURE
Sleeve Gastrectomy
Ring BandedSleeve Gastrectomy
06M 1 yr 2yr 3yr 4yr 5yr 6yr
EB
WL
Follow UP
p vs Baseline always lt0001 BSG LSG
Bhandari M Mathur W etal In Print SOARD
CHOICE OF PROCEDURE
THREE YEARS SIX YEARS
THREE YEARS SIX YEARSLess than 50 50-75 above75 Less than 50 50-75 above75
BSG (0) 0 (2) 35 (56) 965 (0) 0 (4) 83 (44) 917
LSG (15)111 (66)474 (53)395 (46)469 (46)469 (9)91
0102030405060708090
100
BSG
LSG
3 YEARSLSG 111BSG 0
FAILURE RATE
6 YEARSLSG 469BSG 0
CHOICE OF PROCEDURE
CHOICE OF PROCEDURE
Bhandari M Mathur W Mishra A MBRSC Course May 2017 Indore India
The Gastric Bypass is the Gold Standard of Bariatric Metabolic Operations
RGBP BGBP
CHOICE OF PROCEDURE
COMPARISON OF BGBP VS STD GBP
Outcome after the operations BGBP STD GBP
Av Initial weight loss 1-3yrs gt77 65-70
Weight loss 4-10 years 70-77 55-65
Resolution of T2DM 80--85 60-80
VomitingSolid Food Intolerance 5-15 lt5
Significant Weight regain 3-7 10-35
Ringband Erosion 0-2 NA
CHOICE OF PROCEDURE
OAGBPMGB
One Anastamosis Gastric BypassMini Gastric Bypass (OAGBMGB)
Simplicity
Repeatability
Minimal Dissection
Reversibility
Exit Strategy
Safety
Minimal Suturing
Short Duration
Short Learning Curve
CHOICE OF PROCEDURE
OAGBSAGBMGB Advantagesbull Easier operation compared to Standard GBPbull Better food tolerancebull More weight loss than standard GBPbull Better weigh Loss Maintenancebull Higher metabolic effect on T2DM and Hyperlipidemiabull Less incidence of internal herniabull More options for revision if needed
Disadvantagesbull Bile reflux gastritis and esophagitisbull Marginal ulcersbull Nutrient deficienciesbull Protein Caloric Malnutrition
Quan Y Huanh A Ye M Efficacy of laproscopic mini gastric bypass for obesity and type 2 diabetes mellitus A systematic review and met-analysis Gastroenterol Res Pract 2015 ID 152852 10155
CHOICE OF PROCEDURE
2015 ndash Review articleVictorzon M et al Scand J Surg 2015 Mar104(1)48-53 Single-anastomosis gastric
bypass better faster and safer
bull The abstracts of 73 articles were reviewed and after removal of case studies duplicates and irrelevant articles 10 articles remained for closer review
bull Several thousand of this operation have been performed for more than 15 years It is claimed to be an easier safer faster and more effective metabolic operation compared to the standard Roux-en-Y gastric bypass The proponents of this operation also claim that this operation is easier to revise and reverse leaving more options compared to the situation after standard bypass in case of failure However there is much controversy surrounding this method mainly concerning the possible harmful and in the long-term even carcinogenic effects of biliopancreaticoduodenal reflux in the gastric pouch
Comment
Several thousands MGBs performed over 15 yrsEasier safer faster amp more effective than
RYGBEasier to revise amp reverse
Controversy regarding carcinogenic effect of BPD reflux
1306
1213
1294
1218
131
1207
114
116
118
12
122
124
126
128
13
132
Before After
BGB LGB MGB
Hemoglobin
RYGB VS Banded RYGB VS OAGBMGB
CHOICE OF PROCEDURE
399
372
394
36
396
352
32
33
34
35
36
37
38
39
4
41
Before After
BGB LGB MGB
Albumin661
644
693
67
685
607
56
58
6
62
64
66
68
7
Before After
BGB LGB MGB
Protein
RYGB VS Banded RYGB VS OAGBMGB
CHOICE OF PROCEDURE
911
87
906
873
909
833
78
8
82
84
86
88
9
92
Before After
BGB LGB MGB
Calcium
CHOICE OF PROCEDURE
RYGB VS Banded RYGB VS OAGBMGB
COMPARISON OF BGBP OAGB VS STD GBP
Outcome after the operations BGBP OAGBP STD GBP
Av Initial weight loss 1-3yrs gt77 gt77 65-70
Weight loss 4-10 years 70-77 70-77 55-65
Resolution of T2DM 80--85 80-90 60-80
VomitingSolid Food Intolerance 5-15 lt5 lt5
Diarrhea and Steatorrhea 1-2A 15-30 NA
Symptomatic Reflux 1-3 3-11 1-3
Marginal Ulcers 3-5 3-5 3-5
Protein Caloric Malnutrition lt1 3-11 lt1
Significant Weight regain 3-10 3-10 10-35
Ringband Erosion 0-1 NA NA
CHOICE OF PROCEDURE
We have enough information currently to enhance the outcome and minimize the risk by matching the operation to the patient
That is the basis forAn Algorithm for Bariatric Metabolic Operations
CHOOSING THE BEST BARIATRIC METABOLIC PROCEDURE FOR THE PATIENT
CHOICE OF PROCEDURE
bull All agesbull With no diabetesbull With low BMI preferably lt40bull With no GERDbull With HO PUDbull With HO or findings of liver diseasebull With Inflammatory bowel diseasebull With dense adhesions from multiple small bowel surgeriesbull Without HO VTEbull In heavy smokers who are not likely to quitbull In gastric cancer endemic areasbull High Risk needing minimal anesthesia and OR timebull High BMI gt 60 as part of a two stage approach
ALGORITHM
LSG BSG
CHOICE OF PROCEDURE
Laparoscopic Sleeve Gastrectomy Or Banded Sleeve Gastrostomy (SGBSD) Indicated for Patients
-All ages-Patients with T2DM lt5years and HbA1-c lt8 C-Peptidegt2 and not on insulin
-Patients with GERD
-ALL BMI ----- -BGBPBMIlt50-- LGBP
Vegetarian (BGBP)
BGBPLGBP
CHOICE OF PROCEDURE
ALGORITHM
Laparoscopic Gastric Bypass(LGBP) or Banded Gastric Bypass(BGBP) Indicated for Patients
bull With Diabetes gt5 years HbA1cgt8 C-Peptide lt2andor on Insulinbull All agesbull All BMI particularly High BMI-gt50bull High risk patients with need for short anesthesia timebull Because it is an easy to perform procedurebull Best tolerated by non Vegetarian
bull GERD Is a contraindicationbull Liver disease is a contraindication
Must be able to follow up patient regularlyPatient must be able to afford the required supplements OAGB
CHOICE OF PROCEDURE
ALGORITHM
OAGBMGB for patients
Sleeve gastrectomy with duodenal bypass(SGDJB) in patients with indication for Gastric Bypass in Gastric Cancer Endemic Areas
As effective as GBPSame weight loss andmetabolic effects as gastric bypass
SG-DJB
CHOICE OF PROCEDURE
ALGORITHM
Sleeve gastrectomy with duodenal bypass(SGDJB) in patients
1Second stage operation for the sleeve gastrectomy
2 Non responders or complications of sleeve gastric bypass or OAGBMGB
BPD-DS SADI SASI SG with enteral bypass
CHOICE OF PROCEDURE
ALGORITHM
BPD-DS SADI SAGI SASI) Indicated for
Areas with high incidence of anemia and very strict vegetarian food habits
CHOICE OF PROCEDURE
ALGORITHM
Sleeve Gastrectomy with gastro-jejunal gastro-ileal or entero-enteral anastomosis
Intra Gastric Balloon ENDOBARRIER
V-BLOC Aspire AssistEndoscopic Plication
For a patient who does not want an intra abdominal gastro-intestinal procedure
CHOICE OF PROCEDURE
Should You Do A Bariatric Metabolic Operation Because That Is What The Patient Wantsrdquo
NOYESmdashIt depends HoweverA bariatric metabolic surgeon should be able to offer the best operation for the patient based on the patientrsquos profile It is good practice to refer the patient to a tertiary center if the surgeon does not offer the operation that meets the patients indication
CHOICE OF PROCEDURE
CHOOSING THE BEST BARIATRIC METABOLIC PROCEDURE FOR THE PATIENT
CHOICE OF PROCEDURE
Case 157 yo Male BMI 57KgM2 T2DM GERD Strict Vegetarian
Algorithm
Gastric bypass-----Preferably Banded gastric bypassmdash------GERD Vegetarian
Not Sleeve because of T2DM GERD and High BMI
Not OAGBMGB because of GERD and probable of protein deficiency
CHOOSING THE BEST BARIATRIC METABOLIC PROCEDURE FOR THE PATIENT
CHOICE OF PROCEDURE
Case 1128 y0 F BMI 42 PCO DUB OSA and HO Migraine headaches
AlgorithmSleeve GastrectomymdashPreferably a Ring banded Sleeve gastrectomy
----No T2DM---No GERDNot Gastric bypass mdash anemia smelly flatus
Not OAGBMGB----Anemia Foul smelling flatus and body odor----Protein deficiency
CHOOSING THE BEST BARIATRIC METABOLIC PROCEDURE FOR THE PATIENT
CHOICE OF PROCEDURE
Case 11137 yo Male BMI 68 OSA OA and a non vegetarian who works at your hospitalReferred by the pulmonologist at your medical Centre
Algorithm
OAGBMGBmdashHigh BMI Non Veg-better food tolerance patient very likely to be followedand to afford the supplements because of proximity to your center
Not sleeve---poor weight loss with sleeve in super obeseNot Banded sleeve---Good weight loss but poor food tolerance since patient is a non vegetarianNot Gastric bypass---Weight loss in super obese have high non response after gastric bypass
and the gastric bypass is technically a more difficult operation than the OAGBNot Banded gastric bypass ndashGood weight loss but a BGBP is a more difficult operation and
the patient will have some food intolerance because of the ring
SURGICAL TREATMENT OPTIONS
At Mohak we perform these standard three operations and their banded modifications
Sleeve Gastrectomy Gastric Bypass OAGBMGB
CHOICE OF PROCEDURE
Evidence based operations performed at MBRSC From 2010 t0 2017---Standardized OperationsLaparoscopic Sleeve Gastrectomybull 90-120 cc Sleevebull 2-5cm from pylorusbull Where a sleeve is indicated but a band is contraindicated or not affordableBanded Sleeve Gastrectomy (BSG) 84 EWL after 60 monthsbull 90-120 cc Sleevebull 2-5cm from pylorusbull Ring 65-75 cmbull At 3-6 cm below GE junctionBanded Gastric bypass (BGBP) 75 EWL 48 monthsbull Create 6mdash7cm long pouchbull 65-75 cm ring at 3-5 cm below GE junction and gt2cm above anastomosisbull Large Gastroenterostomy gt 2cm bull 100cm Roux Limb and 80 cm BP limb for BMIlt50bull 100cm Roux Limb and 150 cm BP limb for BMIgt50Mini-Gastric Bypass (MGB) (OAGB) 79 EWL 60 monthsbull 9-18cm long pouch ~25cm widebull BP Limb length of 180cm BMIlt50Banded Mini-Gastric Bypass(BMGB)(BOAGB)bull 9-18cm long pouch ~25cm widebull Ring 7-75 cmbull BP Limb length of 180cm BMI50
THE MOHAK PROTOCOLStandardized Bariatric and Robotic Surgery Operations
CHOICE OF PROCEDURE
Sleeve Gastrectomy (LSG) or Banded Sleeve Gastrectomy (BSG)bull Non-diabeticsbull No hiatal hernia or GERDbull HO Smokingbull HO alcohol usebull HO PUDbull Abnormal LFTs NASH and early Cirrhosisbull Pts from areas with high incidence of gastric cancer of H pylori infectionbull High risks patients and super obese patients as part of a two-staged operation
Gastric Bypass (LGBP) or Banded Gastric Bypass (BGBP) or Hybrid BGBPMGBbull Have T2DM with HgbA1c lt 8 and duration lt 5 yearsbull Have Hiatal hernia or GERDbull Are Vegetarianbull No nicotine addiction (smoking)bull Have HO Alcohol intake bull Have NASH at surgery-No cirrhosisbull Not likely to come back for follow up andbull Revision operation of Failed Sleeve gastrectomy GBP or MGB
MOHAK ALGORITHM
CHOICE OF PROCEDURE
One Anastomosis Gastric Bypass-Mini-Gastric Bypass (OAGBP-MGB) bull Have T2DM with HgbA1c 8 and durationgt5 yearsbull Have No GERDbull Are Non-vegetarianbull Have poor dentitionbull Most likely to return for follow up at the clinicbull No HO alcohol intakebull No Nicotine addiction (smoking)bull Normal LFTsbull No NASH at surgery or cirrhosisbull Commitment by our program to have 100 follow up of theses patient
Revision Operationbull Sleeve to Banded RY with 100 cm Al limb and 180 cm BP Limbbull MGB to diverted MGB for Reflux Existing BPL and 100cm ALbull MGB to GBP for PCM or reversal to normal anatomy for PCMmdashinterim gastrostomy feedingbull GBP to BGBP with 180cm BP limb for Weight regain or inadequate weight loss BMIlt40bull GBP to BGBP with 300cm common limb for Weight regain or inadequate weight loss BMIgt40
MOHAK ALGORITHM
CHOICE OF PROCEDURE
bull Laparoscopic Gastric Bypass
bull Laparoscopic Sleeve Gastrectomy
bull Divided Mini-Gastric Bypass
bull Biliopancreatic Diversion with DS
bull Single Anastomosis Duodeno-ileostomy
bull Gastric Plication
bull Banded Gastric Plication
bull Endoscopic Gastroplasty
bull Laparoscopic Adjustable Gastric bands
bull Balloon Implantation
bull Ileal interposition
These other operations will be used selectively based on patients needs and the surgeons determination
CHOICE OF PROCEDURE
The MOHAK Guide for Choice of Bariatric Metabolic Surgery Operations
Single Incision Laparoscopic Robotic and Endoscopic approaches are
available at patientsrsquo requests and the discretion of the surgeon
CHOICE OF PROCEDURE
The MOHAK Guide for Choice of Bariatric Metabolic Surgery Operations
Mohak Bariatrics and Robotics Surgery Center Motto
ldquoThe best operation for the patient by a competent surgeon in a well equipped hospital to maximize outcomes with the least amount of risks exposurerdquo
WE ARE ABLE TO CHOOSE THE BEST BARIATRIC METABOLIC PROCEDURE FOR YOUR PATIENT
Good long-term results are our marketing toolSuccessful patients make a lot of referralsbull
CHOICE OF PROCEDURE
The MOHAK Guide for Choice of Bariatric Metabolic Surgery Operations
We offer various treatment modalities for obesity The operation is
determined by the profile of the patient and guided by findings from
analysis of the data from our prospectively maintained database
MOHAK TEAM INDORE INDIA
THANK YOU
Choice of Operation
1 We currently have a better understanding of the Disease entity Obesity and the determining factors that affect the treatment of obesity
2 Mechanisms of action of various bariatric metabolic operations
AND
3 We know more about the operations---the relative contra-indications and the short and long-term outcomes of the various procedures
CHOICE OF PROCEDURE
THE DISEASE OBESITY
CHOICE OF PROCEDURE
THE DISEASE OBESITY
Obesity is a multi-system disease
Determining factors in the obese that affect the outcome of operations
Co morbid conditions
Risk factors in surgical treatment of obesity
CHOICE OF PROCEDURE
DETERMINING FACTORS
Genetics Expression of ObesityResponse to surgical treatment
Medical Metabolic syndrome T2DM CAD HO VTE Presence or absence of GERD Liver status and Mental Illness
Patient profile BMI Age GenderSocio-psycho-economic Factors
Smoking Alcohol intake Access to post op care Distance from care provider Cost of the operation-Cost and availability of equipment devices and suppliesAffordability of post operative care-Supplements-educational-financial status
DemographicEnvironmental factorsVegetarianAreas endemic to certain problemsmdashCancer UlcersCultural norms
MECHANISMS OF ACTION OF VARIOUS BARIATRIC METABOLIC OPERATIONS
bull Restrictive Effect Control the reservoir size
bull Neural Stimulation of G-E full sense effectsatiation
bull Patient Compliance Forced behavior modification Motivation fear dyspepsia physical activity dietary habit alteration support group participation and physician contact
bull Malabsorptive Effect Bypassed segment of the GI tract results in mal absorption
bull Dumping Effect High caloric fluid and fatty food intolerance
bull Ghrelin Effect Anorexia
bull Foregut effect GIP PYY and Leptin effects
bull Hindgut effect GLP-I motilityNauseasatiation
bull Microbiota effect alteration of the bacterial flora of the gut alters absorption
bull Bile salts
CHOICE OF PROCEDURE
Currently known mechanisms responsible for the effects of the various bariatric metabolic operations include but not limited to
Outcomes of the various operationsWeight Loss and maintenanceResolution of co-morbid conditions---Contra-indications to the various operations--Complications inherent in the operations----
CHOICE OF PROCEDURE
bull Refluxbull Ulcersbull Nutrient deficienciesbull Protein caloric malnutritionbull DiarrheaSteatorrheabull Food Intolerancebull RingBand Migration
The Operations and Procedures
SURGICAL TREATMENT OPTIONS
A Bariatric Metabolic Surgeon should be able to Perform these three basic procedures and their modifications
Sleeve Gastrectomy Gastric Bypass OAGBMGB
CHOICE OF PROCEDURE
CHOICE OF PROCEDURE
Sleeve Gastrectomy Ring BandedSleeve Gastrectomy
The Ring Stabilizes The Size of The Sleeveand minimizes the disadvantagesSEEVE GASTRECTOMY
1 Relatively simple operation2 No disruption of gastrointestinal tract3 No gastro-intestinal anastomosis4 Nearly regular intestinal absorption 5 Low incidence of dumping syndrome6 0 risk of developing an internal hernia 7 Good weight loss and resolution of
co-morbid conditions almost equal to GBP
Disadvantages-Weight loss ltLGBP-Dilation of sleeve with weight regain and recurrence of co-morbid conditions
-Neo-reflux-Intractable leaks-Torsionstenosis-Porto-mesenteric thrombosis
CHOICE OF PROCEDURE
Sleeve Gastrectomy
Ring BandedSleeve Gastrectomy
06M 1 yr 2yr 3yr 4yr 5yr 6yr
EB
WL
Follow UP
p vs Baseline always lt0001 BSG LSG
Bhandari M Mathur W etal In Print SOARD
CHOICE OF PROCEDURE
THREE YEARS SIX YEARS
THREE YEARS SIX YEARSLess than 50 50-75 above75 Less than 50 50-75 above75
BSG (0) 0 (2) 35 (56) 965 (0) 0 (4) 83 (44) 917
LSG (15)111 (66)474 (53)395 (46)469 (46)469 (9)91
0102030405060708090
100
BSG
LSG
3 YEARSLSG 111BSG 0
FAILURE RATE
6 YEARSLSG 469BSG 0
CHOICE OF PROCEDURE
CHOICE OF PROCEDURE
Bhandari M Mathur W Mishra A MBRSC Course May 2017 Indore India
The Gastric Bypass is the Gold Standard of Bariatric Metabolic Operations
RGBP BGBP
CHOICE OF PROCEDURE
COMPARISON OF BGBP VS STD GBP
Outcome after the operations BGBP STD GBP
Av Initial weight loss 1-3yrs gt77 65-70
Weight loss 4-10 years 70-77 55-65
Resolution of T2DM 80--85 60-80
VomitingSolid Food Intolerance 5-15 lt5
Significant Weight regain 3-7 10-35
Ringband Erosion 0-2 NA
CHOICE OF PROCEDURE
OAGBPMGB
One Anastamosis Gastric BypassMini Gastric Bypass (OAGBMGB)
Simplicity
Repeatability
Minimal Dissection
Reversibility
Exit Strategy
Safety
Minimal Suturing
Short Duration
Short Learning Curve
CHOICE OF PROCEDURE
OAGBSAGBMGB Advantagesbull Easier operation compared to Standard GBPbull Better food tolerancebull More weight loss than standard GBPbull Better weigh Loss Maintenancebull Higher metabolic effect on T2DM and Hyperlipidemiabull Less incidence of internal herniabull More options for revision if needed
Disadvantagesbull Bile reflux gastritis and esophagitisbull Marginal ulcersbull Nutrient deficienciesbull Protein Caloric Malnutrition
Quan Y Huanh A Ye M Efficacy of laproscopic mini gastric bypass for obesity and type 2 diabetes mellitus A systematic review and met-analysis Gastroenterol Res Pract 2015 ID 152852 10155
CHOICE OF PROCEDURE
2015 ndash Review articleVictorzon M et al Scand J Surg 2015 Mar104(1)48-53 Single-anastomosis gastric
bypass better faster and safer
bull The abstracts of 73 articles were reviewed and after removal of case studies duplicates and irrelevant articles 10 articles remained for closer review
bull Several thousand of this operation have been performed for more than 15 years It is claimed to be an easier safer faster and more effective metabolic operation compared to the standard Roux-en-Y gastric bypass The proponents of this operation also claim that this operation is easier to revise and reverse leaving more options compared to the situation after standard bypass in case of failure However there is much controversy surrounding this method mainly concerning the possible harmful and in the long-term even carcinogenic effects of biliopancreaticoduodenal reflux in the gastric pouch
Comment
Several thousands MGBs performed over 15 yrsEasier safer faster amp more effective than
RYGBEasier to revise amp reverse
Controversy regarding carcinogenic effect of BPD reflux
1306
1213
1294
1218
131
1207
114
116
118
12
122
124
126
128
13
132
Before After
BGB LGB MGB
Hemoglobin
RYGB VS Banded RYGB VS OAGBMGB
CHOICE OF PROCEDURE
399
372
394
36
396
352
32
33
34
35
36
37
38
39
4
41
Before After
BGB LGB MGB
Albumin661
644
693
67
685
607
56
58
6
62
64
66
68
7
Before After
BGB LGB MGB
Protein
RYGB VS Banded RYGB VS OAGBMGB
CHOICE OF PROCEDURE
911
87
906
873
909
833
78
8
82
84
86
88
9
92
Before After
BGB LGB MGB
Calcium
CHOICE OF PROCEDURE
RYGB VS Banded RYGB VS OAGBMGB
COMPARISON OF BGBP OAGB VS STD GBP
Outcome after the operations BGBP OAGBP STD GBP
Av Initial weight loss 1-3yrs gt77 gt77 65-70
Weight loss 4-10 years 70-77 70-77 55-65
Resolution of T2DM 80--85 80-90 60-80
VomitingSolid Food Intolerance 5-15 lt5 lt5
Diarrhea and Steatorrhea 1-2A 15-30 NA
Symptomatic Reflux 1-3 3-11 1-3
Marginal Ulcers 3-5 3-5 3-5
Protein Caloric Malnutrition lt1 3-11 lt1
Significant Weight regain 3-10 3-10 10-35
Ringband Erosion 0-1 NA NA
CHOICE OF PROCEDURE
We have enough information currently to enhance the outcome and minimize the risk by matching the operation to the patient
That is the basis forAn Algorithm for Bariatric Metabolic Operations
CHOOSING THE BEST BARIATRIC METABOLIC PROCEDURE FOR THE PATIENT
CHOICE OF PROCEDURE
bull All agesbull With no diabetesbull With low BMI preferably lt40bull With no GERDbull With HO PUDbull With HO or findings of liver diseasebull With Inflammatory bowel diseasebull With dense adhesions from multiple small bowel surgeriesbull Without HO VTEbull In heavy smokers who are not likely to quitbull In gastric cancer endemic areasbull High Risk needing minimal anesthesia and OR timebull High BMI gt 60 as part of a two stage approach
ALGORITHM
LSG BSG
CHOICE OF PROCEDURE
Laparoscopic Sleeve Gastrectomy Or Banded Sleeve Gastrostomy (SGBSD) Indicated for Patients
-All ages-Patients with T2DM lt5years and HbA1-c lt8 C-Peptidegt2 and not on insulin
-Patients with GERD
-ALL BMI ----- -BGBPBMIlt50-- LGBP
Vegetarian (BGBP)
BGBPLGBP
CHOICE OF PROCEDURE
ALGORITHM
Laparoscopic Gastric Bypass(LGBP) or Banded Gastric Bypass(BGBP) Indicated for Patients
bull With Diabetes gt5 years HbA1cgt8 C-Peptide lt2andor on Insulinbull All agesbull All BMI particularly High BMI-gt50bull High risk patients with need for short anesthesia timebull Because it is an easy to perform procedurebull Best tolerated by non Vegetarian
bull GERD Is a contraindicationbull Liver disease is a contraindication
Must be able to follow up patient regularlyPatient must be able to afford the required supplements OAGB
CHOICE OF PROCEDURE
ALGORITHM
OAGBMGB for patients
Sleeve gastrectomy with duodenal bypass(SGDJB) in patients with indication for Gastric Bypass in Gastric Cancer Endemic Areas
As effective as GBPSame weight loss andmetabolic effects as gastric bypass
SG-DJB
CHOICE OF PROCEDURE
ALGORITHM
Sleeve gastrectomy with duodenal bypass(SGDJB) in patients
1Second stage operation for the sleeve gastrectomy
2 Non responders or complications of sleeve gastric bypass or OAGBMGB
BPD-DS SADI SASI SG with enteral bypass
CHOICE OF PROCEDURE
ALGORITHM
BPD-DS SADI SAGI SASI) Indicated for
Areas with high incidence of anemia and very strict vegetarian food habits
CHOICE OF PROCEDURE
ALGORITHM
Sleeve Gastrectomy with gastro-jejunal gastro-ileal or entero-enteral anastomosis
Intra Gastric Balloon ENDOBARRIER
V-BLOC Aspire AssistEndoscopic Plication
For a patient who does not want an intra abdominal gastro-intestinal procedure
CHOICE OF PROCEDURE
Should You Do A Bariatric Metabolic Operation Because That Is What The Patient Wantsrdquo
NOYESmdashIt depends HoweverA bariatric metabolic surgeon should be able to offer the best operation for the patient based on the patientrsquos profile It is good practice to refer the patient to a tertiary center if the surgeon does not offer the operation that meets the patients indication
CHOICE OF PROCEDURE
CHOOSING THE BEST BARIATRIC METABOLIC PROCEDURE FOR THE PATIENT
CHOICE OF PROCEDURE
Case 157 yo Male BMI 57KgM2 T2DM GERD Strict Vegetarian
Algorithm
Gastric bypass-----Preferably Banded gastric bypassmdash------GERD Vegetarian
Not Sleeve because of T2DM GERD and High BMI
Not OAGBMGB because of GERD and probable of protein deficiency
CHOOSING THE BEST BARIATRIC METABOLIC PROCEDURE FOR THE PATIENT
CHOICE OF PROCEDURE
Case 1128 y0 F BMI 42 PCO DUB OSA and HO Migraine headaches
AlgorithmSleeve GastrectomymdashPreferably a Ring banded Sleeve gastrectomy
----No T2DM---No GERDNot Gastric bypass mdash anemia smelly flatus
Not OAGBMGB----Anemia Foul smelling flatus and body odor----Protein deficiency
CHOOSING THE BEST BARIATRIC METABOLIC PROCEDURE FOR THE PATIENT
CHOICE OF PROCEDURE
Case 11137 yo Male BMI 68 OSA OA and a non vegetarian who works at your hospitalReferred by the pulmonologist at your medical Centre
Algorithm
OAGBMGBmdashHigh BMI Non Veg-better food tolerance patient very likely to be followedand to afford the supplements because of proximity to your center
Not sleeve---poor weight loss with sleeve in super obeseNot Banded sleeve---Good weight loss but poor food tolerance since patient is a non vegetarianNot Gastric bypass---Weight loss in super obese have high non response after gastric bypass
and the gastric bypass is technically a more difficult operation than the OAGBNot Banded gastric bypass ndashGood weight loss but a BGBP is a more difficult operation and
the patient will have some food intolerance because of the ring
SURGICAL TREATMENT OPTIONS
At Mohak we perform these standard three operations and their banded modifications
Sleeve Gastrectomy Gastric Bypass OAGBMGB
CHOICE OF PROCEDURE
Evidence based operations performed at MBRSC From 2010 t0 2017---Standardized OperationsLaparoscopic Sleeve Gastrectomybull 90-120 cc Sleevebull 2-5cm from pylorusbull Where a sleeve is indicated but a band is contraindicated or not affordableBanded Sleeve Gastrectomy (BSG) 84 EWL after 60 monthsbull 90-120 cc Sleevebull 2-5cm from pylorusbull Ring 65-75 cmbull At 3-6 cm below GE junctionBanded Gastric bypass (BGBP) 75 EWL 48 monthsbull Create 6mdash7cm long pouchbull 65-75 cm ring at 3-5 cm below GE junction and gt2cm above anastomosisbull Large Gastroenterostomy gt 2cm bull 100cm Roux Limb and 80 cm BP limb for BMIlt50bull 100cm Roux Limb and 150 cm BP limb for BMIgt50Mini-Gastric Bypass (MGB) (OAGB) 79 EWL 60 monthsbull 9-18cm long pouch ~25cm widebull BP Limb length of 180cm BMIlt50Banded Mini-Gastric Bypass(BMGB)(BOAGB)bull 9-18cm long pouch ~25cm widebull Ring 7-75 cmbull BP Limb length of 180cm BMI50
THE MOHAK PROTOCOLStandardized Bariatric and Robotic Surgery Operations
CHOICE OF PROCEDURE
Sleeve Gastrectomy (LSG) or Banded Sleeve Gastrectomy (BSG)bull Non-diabeticsbull No hiatal hernia or GERDbull HO Smokingbull HO alcohol usebull HO PUDbull Abnormal LFTs NASH and early Cirrhosisbull Pts from areas with high incidence of gastric cancer of H pylori infectionbull High risks patients and super obese patients as part of a two-staged operation
Gastric Bypass (LGBP) or Banded Gastric Bypass (BGBP) or Hybrid BGBPMGBbull Have T2DM with HgbA1c lt 8 and duration lt 5 yearsbull Have Hiatal hernia or GERDbull Are Vegetarianbull No nicotine addiction (smoking)bull Have HO Alcohol intake bull Have NASH at surgery-No cirrhosisbull Not likely to come back for follow up andbull Revision operation of Failed Sleeve gastrectomy GBP or MGB
MOHAK ALGORITHM
CHOICE OF PROCEDURE
One Anastomosis Gastric Bypass-Mini-Gastric Bypass (OAGBP-MGB) bull Have T2DM with HgbA1c 8 and durationgt5 yearsbull Have No GERDbull Are Non-vegetarianbull Have poor dentitionbull Most likely to return for follow up at the clinicbull No HO alcohol intakebull No Nicotine addiction (smoking)bull Normal LFTsbull No NASH at surgery or cirrhosisbull Commitment by our program to have 100 follow up of theses patient
Revision Operationbull Sleeve to Banded RY with 100 cm Al limb and 180 cm BP Limbbull MGB to diverted MGB for Reflux Existing BPL and 100cm ALbull MGB to GBP for PCM or reversal to normal anatomy for PCMmdashinterim gastrostomy feedingbull GBP to BGBP with 180cm BP limb for Weight regain or inadequate weight loss BMIlt40bull GBP to BGBP with 300cm common limb for Weight regain or inadequate weight loss BMIgt40
MOHAK ALGORITHM
CHOICE OF PROCEDURE
bull Laparoscopic Gastric Bypass
bull Laparoscopic Sleeve Gastrectomy
bull Divided Mini-Gastric Bypass
bull Biliopancreatic Diversion with DS
bull Single Anastomosis Duodeno-ileostomy
bull Gastric Plication
bull Banded Gastric Plication
bull Endoscopic Gastroplasty
bull Laparoscopic Adjustable Gastric bands
bull Balloon Implantation
bull Ileal interposition
These other operations will be used selectively based on patients needs and the surgeons determination
CHOICE OF PROCEDURE
The MOHAK Guide for Choice of Bariatric Metabolic Surgery Operations
Single Incision Laparoscopic Robotic and Endoscopic approaches are
available at patientsrsquo requests and the discretion of the surgeon
CHOICE OF PROCEDURE
The MOHAK Guide for Choice of Bariatric Metabolic Surgery Operations
Mohak Bariatrics and Robotics Surgery Center Motto
ldquoThe best operation for the patient by a competent surgeon in a well equipped hospital to maximize outcomes with the least amount of risks exposurerdquo
WE ARE ABLE TO CHOOSE THE BEST BARIATRIC METABOLIC PROCEDURE FOR YOUR PATIENT
Good long-term results are our marketing toolSuccessful patients make a lot of referralsbull
CHOICE OF PROCEDURE
The MOHAK Guide for Choice of Bariatric Metabolic Surgery Operations
We offer various treatment modalities for obesity The operation is
determined by the profile of the patient and guided by findings from
analysis of the data from our prospectively maintained database
MOHAK TEAM INDORE INDIA
THANK YOU
CHOICE OF PROCEDURE
THE DISEASE OBESITY
CHOICE OF PROCEDURE
THE DISEASE OBESITY
Obesity is a multi-system disease
Determining factors in the obese that affect the outcome of operations
Co morbid conditions
Risk factors in surgical treatment of obesity
CHOICE OF PROCEDURE
DETERMINING FACTORS
Genetics Expression of ObesityResponse to surgical treatment
Medical Metabolic syndrome T2DM CAD HO VTE Presence or absence of GERD Liver status and Mental Illness
Patient profile BMI Age GenderSocio-psycho-economic Factors
Smoking Alcohol intake Access to post op care Distance from care provider Cost of the operation-Cost and availability of equipment devices and suppliesAffordability of post operative care-Supplements-educational-financial status
DemographicEnvironmental factorsVegetarianAreas endemic to certain problemsmdashCancer UlcersCultural norms
MECHANISMS OF ACTION OF VARIOUS BARIATRIC METABOLIC OPERATIONS
bull Restrictive Effect Control the reservoir size
bull Neural Stimulation of G-E full sense effectsatiation
bull Patient Compliance Forced behavior modification Motivation fear dyspepsia physical activity dietary habit alteration support group participation and physician contact
bull Malabsorptive Effect Bypassed segment of the GI tract results in mal absorption
bull Dumping Effect High caloric fluid and fatty food intolerance
bull Ghrelin Effect Anorexia
bull Foregut effect GIP PYY and Leptin effects
bull Hindgut effect GLP-I motilityNauseasatiation
bull Microbiota effect alteration of the bacterial flora of the gut alters absorption
bull Bile salts
CHOICE OF PROCEDURE
Currently known mechanisms responsible for the effects of the various bariatric metabolic operations include but not limited to
Outcomes of the various operationsWeight Loss and maintenanceResolution of co-morbid conditions---Contra-indications to the various operations--Complications inherent in the operations----
CHOICE OF PROCEDURE
bull Refluxbull Ulcersbull Nutrient deficienciesbull Protein caloric malnutritionbull DiarrheaSteatorrheabull Food Intolerancebull RingBand Migration
The Operations and Procedures
SURGICAL TREATMENT OPTIONS
A Bariatric Metabolic Surgeon should be able to Perform these three basic procedures and their modifications
Sleeve Gastrectomy Gastric Bypass OAGBMGB
CHOICE OF PROCEDURE
CHOICE OF PROCEDURE
Sleeve Gastrectomy Ring BandedSleeve Gastrectomy
The Ring Stabilizes The Size of The Sleeveand minimizes the disadvantagesSEEVE GASTRECTOMY
1 Relatively simple operation2 No disruption of gastrointestinal tract3 No gastro-intestinal anastomosis4 Nearly regular intestinal absorption 5 Low incidence of dumping syndrome6 0 risk of developing an internal hernia 7 Good weight loss and resolution of
co-morbid conditions almost equal to GBP
Disadvantages-Weight loss ltLGBP-Dilation of sleeve with weight regain and recurrence of co-morbid conditions
-Neo-reflux-Intractable leaks-Torsionstenosis-Porto-mesenteric thrombosis
CHOICE OF PROCEDURE
Sleeve Gastrectomy
Ring BandedSleeve Gastrectomy
06M 1 yr 2yr 3yr 4yr 5yr 6yr
EB
WL
Follow UP
p vs Baseline always lt0001 BSG LSG
Bhandari M Mathur W etal In Print SOARD
CHOICE OF PROCEDURE
THREE YEARS SIX YEARS
THREE YEARS SIX YEARSLess than 50 50-75 above75 Less than 50 50-75 above75
BSG (0) 0 (2) 35 (56) 965 (0) 0 (4) 83 (44) 917
LSG (15)111 (66)474 (53)395 (46)469 (46)469 (9)91
0102030405060708090
100
BSG
LSG
3 YEARSLSG 111BSG 0
FAILURE RATE
6 YEARSLSG 469BSG 0
CHOICE OF PROCEDURE
CHOICE OF PROCEDURE
Bhandari M Mathur W Mishra A MBRSC Course May 2017 Indore India
The Gastric Bypass is the Gold Standard of Bariatric Metabolic Operations
RGBP BGBP
CHOICE OF PROCEDURE
COMPARISON OF BGBP VS STD GBP
Outcome after the operations BGBP STD GBP
Av Initial weight loss 1-3yrs gt77 65-70
Weight loss 4-10 years 70-77 55-65
Resolution of T2DM 80--85 60-80
VomitingSolid Food Intolerance 5-15 lt5
Significant Weight regain 3-7 10-35
Ringband Erosion 0-2 NA
CHOICE OF PROCEDURE
OAGBPMGB
One Anastamosis Gastric BypassMini Gastric Bypass (OAGBMGB)
Simplicity
Repeatability
Minimal Dissection
Reversibility
Exit Strategy
Safety
Minimal Suturing
Short Duration
Short Learning Curve
CHOICE OF PROCEDURE
OAGBSAGBMGB Advantagesbull Easier operation compared to Standard GBPbull Better food tolerancebull More weight loss than standard GBPbull Better weigh Loss Maintenancebull Higher metabolic effect on T2DM and Hyperlipidemiabull Less incidence of internal herniabull More options for revision if needed
Disadvantagesbull Bile reflux gastritis and esophagitisbull Marginal ulcersbull Nutrient deficienciesbull Protein Caloric Malnutrition
Quan Y Huanh A Ye M Efficacy of laproscopic mini gastric bypass for obesity and type 2 diabetes mellitus A systematic review and met-analysis Gastroenterol Res Pract 2015 ID 152852 10155
CHOICE OF PROCEDURE
2015 ndash Review articleVictorzon M et al Scand J Surg 2015 Mar104(1)48-53 Single-anastomosis gastric
bypass better faster and safer
bull The abstracts of 73 articles were reviewed and after removal of case studies duplicates and irrelevant articles 10 articles remained for closer review
bull Several thousand of this operation have been performed for more than 15 years It is claimed to be an easier safer faster and more effective metabolic operation compared to the standard Roux-en-Y gastric bypass The proponents of this operation also claim that this operation is easier to revise and reverse leaving more options compared to the situation after standard bypass in case of failure However there is much controversy surrounding this method mainly concerning the possible harmful and in the long-term even carcinogenic effects of biliopancreaticoduodenal reflux in the gastric pouch
Comment
Several thousands MGBs performed over 15 yrsEasier safer faster amp more effective than
RYGBEasier to revise amp reverse
Controversy regarding carcinogenic effect of BPD reflux
1306
1213
1294
1218
131
1207
114
116
118
12
122
124
126
128
13
132
Before After
BGB LGB MGB
Hemoglobin
RYGB VS Banded RYGB VS OAGBMGB
CHOICE OF PROCEDURE
399
372
394
36
396
352
32
33
34
35
36
37
38
39
4
41
Before After
BGB LGB MGB
Albumin661
644
693
67
685
607
56
58
6
62
64
66
68
7
Before After
BGB LGB MGB
Protein
RYGB VS Banded RYGB VS OAGBMGB
CHOICE OF PROCEDURE
911
87
906
873
909
833
78
8
82
84
86
88
9
92
Before After
BGB LGB MGB
Calcium
CHOICE OF PROCEDURE
RYGB VS Banded RYGB VS OAGBMGB
COMPARISON OF BGBP OAGB VS STD GBP
Outcome after the operations BGBP OAGBP STD GBP
Av Initial weight loss 1-3yrs gt77 gt77 65-70
Weight loss 4-10 years 70-77 70-77 55-65
Resolution of T2DM 80--85 80-90 60-80
VomitingSolid Food Intolerance 5-15 lt5 lt5
Diarrhea and Steatorrhea 1-2A 15-30 NA
Symptomatic Reflux 1-3 3-11 1-3
Marginal Ulcers 3-5 3-5 3-5
Protein Caloric Malnutrition lt1 3-11 lt1
Significant Weight regain 3-10 3-10 10-35
Ringband Erosion 0-1 NA NA
CHOICE OF PROCEDURE
We have enough information currently to enhance the outcome and minimize the risk by matching the operation to the patient
That is the basis forAn Algorithm for Bariatric Metabolic Operations
CHOOSING THE BEST BARIATRIC METABOLIC PROCEDURE FOR THE PATIENT
CHOICE OF PROCEDURE
bull All agesbull With no diabetesbull With low BMI preferably lt40bull With no GERDbull With HO PUDbull With HO or findings of liver diseasebull With Inflammatory bowel diseasebull With dense adhesions from multiple small bowel surgeriesbull Without HO VTEbull In heavy smokers who are not likely to quitbull In gastric cancer endemic areasbull High Risk needing minimal anesthesia and OR timebull High BMI gt 60 as part of a two stage approach
ALGORITHM
LSG BSG
CHOICE OF PROCEDURE
Laparoscopic Sleeve Gastrectomy Or Banded Sleeve Gastrostomy (SGBSD) Indicated for Patients
-All ages-Patients with T2DM lt5years and HbA1-c lt8 C-Peptidegt2 and not on insulin
-Patients with GERD
-ALL BMI ----- -BGBPBMIlt50-- LGBP
Vegetarian (BGBP)
BGBPLGBP
CHOICE OF PROCEDURE
ALGORITHM
Laparoscopic Gastric Bypass(LGBP) or Banded Gastric Bypass(BGBP) Indicated for Patients
bull With Diabetes gt5 years HbA1cgt8 C-Peptide lt2andor on Insulinbull All agesbull All BMI particularly High BMI-gt50bull High risk patients with need for short anesthesia timebull Because it is an easy to perform procedurebull Best tolerated by non Vegetarian
bull GERD Is a contraindicationbull Liver disease is a contraindication
Must be able to follow up patient regularlyPatient must be able to afford the required supplements OAGB
CHOICE OF PROCEDURE
ALGORITHM
OAGBMGB for patients
Sleeve gastrectomy with duodenal bypass(SGDJB) in patients with indication for Gastric Bypass in Gastric Cancer Endemic Areas
As effective as GBPSame weight loss andmetabolic effects as gastric bypass
SG-DJB
CHOICE OF PROCEDURE
ALGORITHM
Sleeve gastrectomy with duodenal bypass(SGDJB) in patients
1Second stage operation for the sleeve gastrectomy
2 Non responders or complications of sleeve gastric bypass or OAGBMGB
BPD-DS SADI SASI SG with enteral bypass
CHOICE OF PROCEDURE
ALGORITHM
BPD-DS SADI SAGI SASI) Indicated for
Areas with high incidence of anemia and very strict vegetarian food habits
CHOICE OF PROCEDURE
ALGORITHM
Sleeve Gastrectomy with gastro-jejunal gastro-ileal or entero-enteral anastomosis
Intra Gastric Balloon ENDOBARRIER
V-BLOC Aspire AssistEndoscopic Plication
For a patient who does not want an intra abdominal gastro-intestinal procedure
CHOICE OF PROCEDURE
Should You Do A Bariatric Metabolic Operation Because That Is What The Patient Wantsrdquo
NOYESmdashIt depends HoweverA bariatric metabolic surgeon should be able to offer the best operation for the patient based on the patientrsquos profile It is good practice to refer the patient to a tertiary center if the surgeon does not offer the operation that meets the patients indication
CHOICE OF PROCEDURE
CHOOSING THE BEST BARIATRIC METABOLIC PROCEDURE FOR THE PATIENT
CHOICE OF PROCEDURE
Case 157 yo Male BMI 57KgM2 T2DM GERD Strict Vegetarian
Algorithm
Gastric bypass-----Preferably Banded gastric bypassmdash------GERD Vegetarian
Not Sleeve because of T2DM GERD and High BMI
Not OAGBMGB because of GERD and probable of protein deficiency
CHOOSING THE BEST BARIATRIC METABOLIC PROCEDURE FOR THE PATIENT
CHOICE OF PROCEDURE
Case 1128 y0 F BMI 42 PCO DUB OSA and HO Migraine headaches
AlgorithmSleeve GastrectomymdashPreferably a Ring banded Sleeve gastrectomy
----No T2DM---No GERDNot Gastric bypass mdash anemia smelly flatus
Not OAGBMGB----Anemia Foul smelling flatus and body odor----Protein deficiency
CHOOSING THE BEST BARIATRIC METABOLIC PROCEDURE FOR THE PATIENT
CHOICE OF PROCEDURE
Case 11137 yo Male BMI 68 OSA OA and a non vegetarian who works at your hospitalReferred by the pulmonologist at your medical Centre
Algorithm
OAGBMGBmdashHigh BMI Non Veg-better food tolerance patient very likely to be followedand to afford the supplements because of proximity to your center
Not sleeve---poor weight loss with sleeve in super obeseNot Banded sleeve---Good weight loss but poor food tolerance since patient is a non vegetarianNot Gastric bypass---Weight loss in super obese have high non response after gastric bypass
and the gastric bypass is technically a more difficult operation than the OAGBNot Banded gastric bypass ndashGood weight loss but a BGBP is a more difficult operation and
the patient will have some food intolerance because of the ring
SURGICAL TREATMENT OPTIONS
At Mohak we perform these standard three operations and their banded modifications
Sleeve Gastrectomy Gastric Bypass OAGBMGB
CHOICE OF PROCEDURE
Evidence based operations performed at MBRSC From 2010 t0 2017---Standardized OperationsLaparoscopic Sleeve Gastrectomybull 90-120 cc Sleevebull 2-5cm from pylorusbull Where a sleeve is indicated but a band is contraindicated or not affordableBanded Sleeve Gastrectomy (BSG) 84 EWL after 60 monthsbull 90-120 cc Sleevebull 2-5cm from pylorusbull Ring 65-75 cmbull At 3-6 cm below GE junctionBanded Gastric bypass (BGBP) 75 EWL 48 monthsbull Create 6mdash7cm long pouchbull 65-75 cm ring at 3-5 cm below GE junction and gt2cm above anastomosisbull Large Gastroenterostomy gt 2cm bull 100cm Roux Limb and 80 cm BP limb for BMIlt50bull 100cm Roux Limb and 150 cm BP limb for BMIgt50Mini-Gastric Bypass (MGB) (OAGB) 79 EWL 60 monthsbull 9-18cm long pouch ~25cm widebull BP Limb length of 180cm BMIlt50Banded Mini-Gastric Bypass(BMGB)(BOAGB)bull 9-18cm long pouch ~25cm widebull Ring 7-75 cmbull BP Limb length of 180cm BMI50
THE MOHAK PROTOCOLStandardized Bariatric and Robotic Surgery Operations
CHOICE OF PROCEDURE
Sleeve Gastrectomy (LSG) or Banded Sleeve Gastrectomy (BSG)bull Non-diabeticsbull No hiatal hernia or GERDbull HO Smokingbull HO alcohol usebull HO PUDbull Abnormal LFTs NASH and early Cirrhosisbull Pts from areas with high incidence of gastric cancer of H pylori infectionbull High risks patients and super obese patients as part of a two-staged operation
Gastric Bypass (LGBP) or Banded Gastric Bypass (BGBP) or Hybrid BGBPMGBbull Have T2DM with HgbA1c lt 8 and duration lt 5 yearsbull Have Hiatal hernia or GERDbull Are Vegetarianbull No nicotine addiction (smoking)bull Have HO Alcohol intake bull Have NASH at surgery-No cirrhosisbull Not likely to come back for follow up andbull Revision operation of Failed Sleeve gastrectomy GBP or MGB
MOHAK ALGORITHM
CHOICE OF PROCEDURE
One Anastomosis Gastric Bypass-Mini-Gastric Bypass (OAGBP-MGB) bull Have T2DM with HgbA1c 8 and durationgt5 yearsbull Have No GERDbull Are Non-vegetarianbull Have poor dentitionbull Most likely to return for follow up at the clinicbull No HO alcohol intakebull No Nicotine addiction (smoking)bull Normal LFTsbull No NASH at surgery or cirrhosisbull Commitment by our program to have 100 follow up of theses patient
Revision Operationbull Sleeve to Banded RY with 100 cm Al limb and 180 cm BP Limbbull MGB to diverted MGB for Reflux Existing BPL and 100cm ALbull MGB to GBP for PCM or reversal to normal anatomy for PCMmdashinterim gastrostomy feedingbull GBP to BGBP with 180cm BP limb for Weight regain or inadequate weight loss BMIlt40bull GBP to BGBP with 300cm common limb for Weight regain or inadequate weight loss BMIgt40
MOHAK ALGORITHM
CHOICE OF PROCEDURE
bull Laparoscopic Gastric Bypass
bull Laparoscopic Sleeve Gastrectomy
bull Divided Mini-Gastric Bypass
bull Biliopancreatic Diversion with DS
bull Single Anastomosis Duodeno-ileostomy
bull Gastric Plication
bull Banded Gastric Plication
bull Endoscopic Gastroplasty
bull Laparoscopic Adjustable Gastric bands
bull Balloon Implantation
bull Ileal interposition
These other operations will be used selectively based on patients needs and the surgeons determination
CHOICE OF PROCEDURE
The MOHAK Guide for Choice of Bariatric Metabolic Surgery Operations
Single Incision Laparoscopic Robotic and Endoscopic approaches are
available at patientsrsquo requests and the discretion of the surgeon
CHOICE OF PROCEDURE
The MOHAK Guide for Choice of Bariatric Metabolic Surgery Operations
Mohak Bariatrics and Robotics Surgery Center Motto
ldquoThe best operation for the patient by a competent surgeon in a well equipped hospital to maximize outcomes with the least amount of risks exposurerdquo
WE ARE ABLE TO CHOOSE THE BEST BARIATRIC METABOLIC PROCEDURE FOR YOUR PATIENT
Good long-term results are our marketing toolSuccessful patients make a lot of referralsbull
CHOICE OF PROCEDURE
The MOHAK Guide for Choice of Bariatric Metabolic Surgery Operations
We offer various treatment modalities for obesity The operation is
determined by the profile of the patient and guided by findings from
analysis of the data from our prospectively maintained database
MOHAK TEAM INDORE INDIA
THANK YOU
CHOICE OF PROCEDURE
THE DISEASE OBESITY
Obesity is a multi-system disease
Determining factors in the obese that affect the outcome of operations
Co morbid conditions
Risk factors in surgical treatment of obesity
CHOICE OF PROCEDURE
DETERMINING FACTORS
Genetics Expression of ObesityResponse to surgical treatment
Medical Metabolic syndrome T2DM CAD HO VTE Presence or absence of GERD Liver status and Mental Illness
Patient profile BMI Age GenderSocio-psycho-economic Factors
Smoking Alcohol intake Access to post op care Distance from care provider Cost of the operation-Cost and availability of equipment devices and suppliesAffordability of post operative care-Supplements-educational-financial status
DemographicEnvironmental factorsVegetarianAreas endemic to certain problemsmdashCancer UlcersCultural norms
MECHANISMS OF ACTION OF VARIOUS BARIATRIC METABOLIC OPERATIONS
bull Restrictive Effect Control the reservoir size
bull Neural Stimulation of G-E full sense effectsatiation
bull Patient Compliance Forced behavior modification Motivation fear dyspepsia physical activity dietary habit alteration support group participation and physician contact
bull Malabsorptive Effect Bypassed segment of the GI tract results in mal absorption
bull Dumping Effect High caloric fluid and fatty food intolerance
bull Ghrelin Effect Anorexia
bull Foregut effect GIP PYY and Leptin effects
bull Hindgut effect GLP-I motilityNauseasatiation
bull Microbiota effect alteration of the bacterial flora of the gut alters absorption
bull Bile salts
CHOICE OF PROCEDURE
Currently known mechanisms responsible for the effects of the various bariatric metabolic operations include but not limited to
Outcomes of the various operationsWeight Loss and maintenanceResolution of co-morbid conditions---Contra-indications to the various operations--Complications inherent in the operations----
CHOICE OF PROCEDURE
bull Refluxbull Ulcersbull Nutrient deficienciesbull Protein caloric malnutritionbull DiarrheaSteatorrheabull Food Intolerancebull RingBand Migration
The Operations and Procedures
SURGICAL TREATMENT OPTIONS
A Bariatric Metabolic Surgeon should be able to Perform these three basic procedures and their modifications
Sleeve Gastrectomy Gastric Bypass OAGBMGB
CHOICE OF PROCEDURE
CHOICE OF PROCEDURE
Sleeve Gastrectomy Ring BandedSleeve Gastrectomy
The Ring Stabilizes The Size of The Sleeveand minimizes the disadvantagesSEEVE GASTRECTOMY
1 Relatively simple operation2 No disruption of gastrointestinal tract3 No gastro-intestinal anastomosis4 Nearly regular intestinal absorption 5 Low incidence of dumping syndrome6 0 risk of developing an internal hernia 7 Good weight loss and resolution of
co-morbid conditions almost equal to GBP
Disadvantages-Weight loss ltLGBP-Dilation of sleeve with weight regain and recurrence of co-morbid conditions
-Neo-reflux-Intractable leaks-Torsionstenosis-Porto-mesenteric thrombosis
CHOICE OF PROCEDURE
Sleeve Gastrectomy
Ring BandedSleeve Gastrectomy
06M 1 yr 2yr 3yr 4yr 5yr 6yr
EB
WL
Follow UP
p vs Baseline always lt0001 BSG LSG
Bhandari M Mathur W etal In Print SOARD
CHOICE OF PROCEDURE
THREE YEARS SIX YEARS
THREE YEARS SIX YEARSLess than 50 50-75 above75 Less than 50 50-75 above75
BSG (0) 0 (2) 35 (56) 965 (0) 0 (4) 83 (44) 917
LSG (15)111 (66)474 (53)395 (46)469 (46)469 (9)91
0102030405060708090
100
BSG
LSG
3 YEARSLSG 111BSG 0
FAILURE RATE
6 YEARSLSG 469BSG 0
CHOICE OF PROCEDURE
CHOICE OF PROCEDURE
Bhandari M Mathur W Mishra A MBRSC Course May 2017 Indore India
The Gastric Bypass is the Gold Standard of Bariatric Metabolic Operations
RGBP BGBP
CHOICE OF PROCEDURE
COMPARISON OF BGBP VS STD GBP
Outcome after the operations BGBP STD GBP
Av Initial weight loss 1-3yrs gt77 65-70
Weight loss 4-10 years 70-77 55-65
Resolution of T2DM 80--85 60-80
VomitingSolid Food Intolerance 5-15 lt5
Significant Weight regain 3-7 10-35
Ringband Erosion 0-2 NA
CHOICE OF PROCEDURE
OAGBPMGB
One Anastamosis Gastric BypassMini Gastric Bypass (OAGBMGB)
Simplicity
Repeatability
Minimal Dissection
Reversibility
Exit Strategy
Safety
Minimal Suturing
Short Duration
Short Learning Curve
CHOICE OF PROCEDURE
OAGBSAGBMGB Advantagesbull Easier operation compared to Standard GBPbull Better food tolerancebull More weight loss than standard GBPbull Better weigh Loss Maintenancebull Higher metabolic effect on T2DM and Hyperlipidemiabull Less incidence of internal herniabull More options for revision if needed
Disadvantagesbull Bile reflux gastritis and esophagitisbull Marginal ulcersbull Nutrient deficienciesbull Protein Caloric Malnutrition
Quan Y Huanh A Ye M Efficacy of laproscopic mini gastric bypass for obesity and type 2 diabetes mellitus A systematic review and met-analysis Gastroenterol Res Pract 2015 ID 152852 10155
CHOICE OF PROCEDURE
2015 ndash Review articleVictorzon M et al Scand J Surg 2015 Mar104(1)48-53 Single-anastomosis gastric
bypass better faster and safer
bull The abstracts of 73 articles were reviewed and after removal of case studies duplicates and irrelevant articles 10 articles remained for closer review
bull Several thousand of this operation have been performed for more than 15 years It is claimed to be an easier safer faster and more effective metabolic operation compared to the standard Roux-en-Y gastric bypass The proponents of this operation also claim that this operation is easier to revise and reverse leaving more options compared to the situation after standard bypass in case of failure However there is much controversy surrounding this method mainly concerning the possible harmful and in the long-term even carcinogenic effects of biliopancreaticoduodenal reflux in the gastric pouch
Comment
Several thousands MGBs performed over 15 yrsEasier safer faster amp more effective than
RYGBEasier to revise amp reverse
Controversy regarding carcinogenic effect of BPD reflux
1306
1213
1294
1218
131
1207
114
116
118
12
122
124
126
128
13
132
Before After
BGB LGB MGB
Hemoglobin
RYGB VS Banded RYGB VS OAGBMGB
CHOICE OF PROCEDURE
399
372
394
36
396
352
32
33
34
35
36
37
38
39
4
41
Before After
BGB LGB MGB
Albumin661
644
693
67
685
607
56
58
6
62
64
66
68
7
Before After
BGB LGB MGB
Protein
RYGB VS Banded RYGB VS OAGBMGB
CHOICE OF PROCEDURE
911
87
906
873
909
833
78
8
82
84
86
88
9
92
Before After
BGB LGB MGB
Calcium
CHOICE OF PROCEDURE
RYGB VS Banded RYGB VS OAGBMGB
COMPARISON OF BGBP OAGB VS STD GBP
Outcome after the operations BGBP OAGBP STD GBP
Av Initial weight loss 1-3yrs gt77 gt77 65-70
Weight loss 4-10 years 70-77 70-77 55-65
Resolution of T2DM 80--85 80-90 60-80
VomitingSolid Food Intolerance 5-15 lt5 lt5
Diarrhea and Steatorrhea 1-2A 15-30 NA
Symptomatic Reflux 1-3 3-11 1-3
Marginal Ulcers 3-5 3-5 3-5
Protein Caloric Malnutrition lt1 3-11 lt1
Significant Weight regain 3-10 3-10 10-35
Ringband Erosion 0-1 NA NA
CHOICE OF PROCEDURE
We have enough information currently to enhance the outcome and minimize the risk by matching the operation to the patient
That is the basis forAn Algorithm for Bariatric Metabolic Operations
CHOOSING THE BEST BARIATRIC METABOLIC PROCEDURE FOR THE PATIENT
CHOICE OF PROCEDURE
bull All agesbull With no diabetesbull With low BMI preferably lt40bull With no GERDbull With HO PUDbull With HO or findings of liver diseasebull With Inflammatory bowel diseasebull With dense adhesions from multiple small bowel surgeriesbull Without HO VTEbull In heavy smokers who are not likely to quitbull In gastric cancer endemic areasbull High Risk needing minimal anesthesia and OR timebull High BMI gt 60 as part of a two stage approach
ALGORITHM
LSG BSG
CHOICE OF PROCEDURE
Laparoscopic Sleeve Gastrectomy Or Banded Sleeve Gastrostomy (SGBSD) Indicated for Patients
-All ages-Patients with T2DM lt5years and HbA1-c lt8 C-Peptidegt2 and not on insulin
-Patients with GERD
-ALL BMI ----- -BGBPBMIlt50-- LGBP
Vegetarian (BGBP)
BGBPLGBP
CHOICE OF PROCEDURE
ALGORITHM
Laparoscopic Gastric Bypass(LGBP) or Banded Gastric Bypass(BGBP) Indicated for Patients
bull With Diabetes gt5 years HbA1cgt8 C-Peptide lt2andor on Insulinbull All agesbull All BMI particularly High BMI-gt50bull High risk patients with need for short anesthesia timebull Because it is an easy to perform procedurebull Best tolerated by non Vegetarian
bull GERD Is a contraindicationbull Liver disease is a contraindication
Must be able to follow up patient regularlyPatient must be able to afford the required supplements OAGB
CHOICE OF PROCEDURE
ALGORITHM
OAGBMGB for patients
Sleeve gastrectomy with duodenal bypass(SGDJB) in patients with indication for Gastric Bypass in Gastric Cancer Endemic Areas
As effective as GBPSame weight loss andmetabolic effects as gastric bypass
SG-DJB
CHOICE OF PROCEDURE
ALGORITHM
Sleeve gastrectomy with duodenal bypass(SGDJB) in patients
1Second stage operation for the sleeve gastrectomy
2 Non responders or complications of sleeve gastric bypass or OAGBMGB
BPD-DS SADI SASI SG with enteral bypass
CHOICE OF PROCEDURE
ALGORITHM
BPD-DS SADI SAGI SASI) Indicated for
Areas with high incidence of anemia and very strict vegetarian food habits
CHOICE OF PROCEDURE
ALGORITHM
Sleeve Gastrectomy with gastro-jejunal gastro-ileal or entero-enteral anastomosis
Intra Gastric Balloon ENDOBARRIER
V-BLOC Aspire AssistEndoscopic Plication
For a patient who does not want an intra abdominal gastro-intestinal procedure
CHOICE OF PROCEDURE
Should You Do A Bariatric Metabolic Operation Because That Is What The Patient Wantsrdquo
NOYESmdashIt depends HoweverA bariatric metabolic surgeon should be able to offer the best operation for the patient based on the patientrsquos profile It is good practice to refer the patient to a tertiary center if the surgeon does not offer the operation that meets the patients indication
CHOICE OF PROCEDURE
CHOOSING THE BEST BARIATRIC METABOLIC PROCEDURE FOR THE PATIENT
CHOICE OF PROCEDURE
Case 157 yo Male BMI 57KgM2 T2DM GERD Strict Vegetarian
Algorithm
Gastric bypass-----Preferably Banded gastric bypassmdash------GERD Vegetarian
Not Sleeve because of T2DM GERD and High BMI
Not OAGBMGB because of GERD and probable of protein deficiency
CHOOSING THE BEST BARIATRIC METABOLIC PROCEDURE FOR THE PATIENT
CHOICE OF PROCEDURE
Case 1128 y0 F BMI 42 PCO DUB OSA and HO Migraine headaches
AlgorithmSleeve GastrectomymdashPreferably a Ring banded Sleeve gastrectomy
----No T2DM---No GERDNot Gastric bypass mdash anemia smelly flatus
Not OAGBMGB----Anemia Foul smelling flatus and body odor----Protein deficiency
CHOOSING THE BEST BARIATRIC METABOLIC PROCEDURE FOR THE PATIENT
CHOICE OF PROCEDURE
Case 11137 yo Male BMI 68 OSA OA and a non vegetarian who works at your hospitalReferred by the pulmonologist at your medical Centre
Algorithm
OAGBMGBmdashHigh BMI Non Veg-better food tolerance patient very likely to be followedand to afford the supplements because of proximity to your center
Not sleeve---poor weight loss with sleeve in super obeseNot Banded sleeve---Good weight loss but poor food tolerance since patient is a non vegetarianNot Gastric bypass---Weight loss in super obese have high non response after gastric bypass
and the gastric bypass is technically a more difficult operation than the OAGBNot Banded gastric bypass ndashGood weight loss but a BGBP is a more difficult operation and
the patient will have some food intolerance because of the ring
SURGICAL TREATMENT OPTIONS
At Mohak we perform these standard three operations and their banded modifications
Sleeve Gastrectomy Gastric Bypass OAGBMGB
CHOICE OF PROCEDURE
Evidence based operations performed at MBRSC From 2010 t0 2017---Standardized OperationsLaparoscopic Sleeve Gastrectomybull 90-120 cc Sleevebull 2-5cm from pylorusbull Where a sleeve is indicated but a band is contraindicated or not affordableBanded Sleeve Gastrectomy (BSG) 84 EWL after 60 monthsbull 90-120 cc Sleevebull 2-5cm from pylorusbull Ring 65-75 cmbull At 3-6 cm below GE junctionBanded Gastric bypass (BGBP) 75 EWL 48 monthsbull Create 6mdash7cm long pouchbull 65-75 cm ring at 3-5 cm below GE junction and gt2cm above anastomosisbull Large Gastroenterostomy gt 2cm bull 100cm Roux Limb and 80 cm BP limb for BMIlt50bull 100cm Roux Limb and 150 cm BP limb for BMIgt50Mini-Gastric Bypass (MGB) (OAGB) 79 EWL 60 monthsbull 9-18cm long pouch ~25cm widebull BP Limb length of 180cm BMIlt50Banded Mini-Gastric Bypass(BMGB)(BOAGB)bull 9-18cm long pouch ~25cm widebull Ring 7-75 cmbull BP Limb length of 180cm BMI50
THE MOHAK PROTOCOLStandardized Bariatric and Robotic Surgery Operations
CHOICE OF PROCEDURE
Sleeve Gastrectomy (LSG) or Banded Sleeve Gastrectomy (BSG)bull Non-diabeticsbull No hiatal hernia or GERDbull HO Smokingbull HO alcohol usebull HO PUDbull Abnormal LFTs NASH and early Cirrhosisbull Pts from areas with high incidence of gastric cancer of H pylori infectionbull High risks patients and super obese patients as part of a two-staged operation
Gastric Bypass (LGBP) or Banded Gastric Bypass (BGBP) or Hybrid BGBPMGBbull Have T2DM with HgbA1c lt 8 and duration lt 5 yearsbull Have Hiatal hernia or GERDbull Are Vegetarianbull No nicotine addiction (smoking)bull Have HO Alcohol intake bull Have NASH at surgery-No cirrhosisbull Not likely to come back for follow up andbull Revision operation of Failed Sleeve gastrectomy GBP or MGB
MOHAK ALGORITHM
CHOICE OF PROCEDURE
One Anastomosis Gastric Bypass-Mini-Gastric Bypass (OAGBP-MGB) bull Have T2DM with HgbA1c 8 and durationgt5 yearsbull Have No GERDbull Are Non-vegetarianbull Have poor dentitionbull Most likely to return for follow up at the clinicbull No HO alcohol intakebull No Nicotine addiction (smoking)bull Normal LFTsbull No NASH at surgery or cirrhosisbull Commitment by our program to have 100 follow up of theses patient
Revision Operationbull Sleeve to Banded RY with 100 cm Al limb and 180 cm BP Limbbull MGB to diverted MGB for Reflux Existing BPL and 100cm ALbull MGB to GBP for PCM or reversal to normal anatomy for PCMmdashinterim gastrostomy feedingbull GBP to BGBP with 180cm BP limb for Weight regain or inadequate weight loss BMIlt40bull GBP to BGBP with 300cm common limb for Weight regain or inadequate weight loss BMIgt40
MOHAK ALGORITHM
CHOICE OF PROCEDURE
bull Laparoscopic Gastric Bypass
bull Laparoscopic Sleeve Gastrectomy
bull Divided Mini-Gastric Bypass
bull Biliopancreatic Diversion with DS
bull Single Anastomosis Duodeno-ileostomy
bull Gastric Plication
bull Banded Gastric Plication
bull Endoscopic Gastroplasty
bull Laparoscopic Adjustable Gastric bands
bull Balloon Implantation
bull Ileal interposition
These other operations will be used selectively based on patients needs and the surgeons determination
CHOICE OF PROCEDURE
The MOHAK Guide for Choice of Bariatric Metabolic Surgery Operations
Single Incision Laparoscopic Robotic and Endoscopic approaches are
available at patientsrsquo requests and the discretion of the surgeon
CHOICE OF PROCEDURE
The MOHAK Guide for Choice of Bariatric Metabolic Surgery Operations
Mohak Bariatrics and Robotics Surgery Center Motto
ldquoThe best operation for the patient by a competent surgeon in a well equipped hospital to maximize outcomes with the least amount of risks exposurerdquo
WE ARE ABLE TO CHOOSE THE BEST BARIATRIC METABOLIC PROCEDURE FOR YOUR PATIENT
Good long-term results are our marketing toolSuccessful patients make a lot of referralsbull
CHOICE OF PROCEDURE
The MOHAK Guide for Choice of Bariatric Metabolic Surgery Operations
We offer various treatment modalities for obesity The operation is
determined by the profile of the patient and guided by findings from
analysis of the data from our prospectively maintained database
MOHAK TEAM INDORE INDIA
THANK YOU
CHOICE OF PROCEDURE
DETERMINING FACTORS
Genetics Expression of ObesityResponse to surgical treatment
Medical Metabolic syndrome T2DM CAD HO VTE Presence or absence of GERD Liver status and Mental Illness
Patient profile BMI Age GenderSocio-psycho-economic Factors
Smoking Alcohol intake Access to post op care Distance from care provider Cost of the operation-Cost and availability of equipment devices and suppliesAffordability of post operative care-Supplements-educational-financial status
DemographicEnvironmental factorsVegetarianAreas endemic to certain problemsmdashCancer UlcersCultural norms
MECHANISMS OF ACTION OF VARIOUS BARIATRIC METABOLIC OPERATIONS
bull Restrictive Effect Control the reservoir size
bull Neural Stimulation of G-E full sense effectsatiation
bull Patient Compliance Forced behavior modification Motivation fear dyspepsia physical activity dietary habit alteration support group participation and physician contact
bull Malabsorptive Effect Bypassed segment of the GI tract results in mal absorption
bull Dumping Effect High caloric fluid and fatty food intolerance
bull Ghrelin Effect Anorexia
bull Foregut effect GIP PYY and Leptin effects
bull Hindgut effect GLP-I motilityNauseasatiation
bull Microbiota effect alteration of the bacterial flora of the gut alters absorption
bull Bile salts
CHOICE OF PROCEDURE
Currently known mechanisms responsible for the effects of the various bariatric metabolic operations include but not limited to
Outcomes of the various operationsWeight Loss and maintenanceResolution of co-morbid conditions---Contra-indications to the various operations--Complications inherent in the operations----
CHOICE OF PROCEDURE
bull Refluxbull Ulcersbull Nutrient deficienciesbull Protein caloric malnutritionbull DiarrheaSteatorrheabull Food Intolerancebull RingBand Migration
The Operations and Procedures
SURGICAL TREATMENT OPTIONS
A Bariatric Metabolic Surgeon should be able to Perform these three basic procedures and their modifications
Sleeve Gastrectomy Gastric Bypass OAGBMGB
CHOICE OF PROCEDURE
CHOICE OF PROCEDURE
Sleeve Gastrectomy Ring BandedSleeve Gastrectomy
The Ring Stabilizes The Size of The Sleeveand minimizes the disadvantagesSEEVE GASTRECTOMY
1 Relatively simple operation2 No disruption of gastrointestinal tract3 No gastro-intestinal anastomosis4 Nearly regular intestinal absorption 5 Low incidence of dumping syndrome6 0 risk of developing an internal hernia 7 Good weight loss and resolution of
co-morbid conditions almost equal to GBP
Disadvantages-Weight loss ltLGBP-Dilation of sleeve with weight regain and recurrence of co-morbid conditions
-Neo-reflux-Intractable leaks-Torsionstenosis-Porto-mesenteric thrombosis
CHOICE OF PROCEDURE
Sleeve Gastrectomy
Ring BandedSleeve Gastrectomy
06M 1 yr 2yr 3yr 4yr 5yr 6yr
EB
WL
Follow UP
p vs Baseline always lt0001 BSG LSG
Bhandari M Mathur W etal In Print SOARD
CHOICE OF PROCEDURE
THREE YEARS SIX YEARS
THREE YEARS SIX YEARSLess than 50 50-75 above75 Less than 50 50-75 above75
BSG (0) 0 (2) 35 (56) 965 (0) 0 (4) 83 (44) 917
LSG (15)111 (66)474 (53)395 (46)469 (46)469 (9)91
0102030405060708090
100
BSG
LSG
3 YEARSLSG 111BSG 0
FAILURE RATE
6 YEARSLSG 469BSG 0
CHOICE OF PROCEDURE
CHOICE OF PROCEDURE
Bhandari M Mathur W Mishra A MBRSC Course May 2017 Indore India
The Gastric Bypass is the Gold Standard of Bariatric Metabolic Operations
RGBP BGBP
CHOICE OF PROCEDURE
COMPARISON OF BGBP VS STD GBP
Outcome after the operations BGBP STD GBP
Av Initial weight loss 1-3yrs gt77 65-70
Weight loss 4-10 years 70-77 55-65
Resolution of T2DM 80--85 60-80
VomitingSolid Food Intolerance 5-15 lt5
Significant Weight regain 3-7 10-35
Ringband Erosion 0-2 NA
CHOICE OF PROCEDURE
OAGBPMGB
One Anastamosis Gastric BypassMini Gastric Bypass (OAGBMGB)
Simplicity
Repeatability
Minimal Dissection
Reversibility
Exit Strategy
Safety
Minimal Suturing
Short Duration
Short Learning Curve
CHOICE OF PROCEDURE
OAGBSAGBMGB Advantagesbull Easier operation compared to Standard GBPbull Better food tolerancebull More weight loss than standard GBPbull Better weigh Loss Maintenancebull Higher metabolic effect on T2DM and Hyperlipidemiabull Less incidence of internal herniabull More options for revision if needed
Disadvantagesbull Bile reflux gastritis and esophagitisbull Marginal ulcersbull Nutrient deficienciesbull Protein Caloric Malnutrition
Quan Y Huanh A Ye M Efficacy of laproscopic mini gastric bypass for obesity and type 2 diabetes mellitus A systematic review and met-analysis Gastroenterol Res Pract 2015 ID 152852 10155
CHOICE OF PROCEDURE
2015 ndash Review articleVictorzon M et al Scand J Surg 2015 Mar104(1)48-53 Single-anastomosis gastric
bypass better faster and safer
bull The abstracts of 73 articles were reviewed and after removal of case studies duplicates and irrelevant articles 10 articles remained for closer review
bull Several thousand of this operation have been performed for more than 15 years It is claimed to be an easier safer faster and more effective metabolic operation compared to the standard Roux-en-Y gastric bypass The proponents of this operation also claim that this operation is easier to revise and reverse leaving more options compared to the situation after standard bypass in case of failure However there is much controversy surrounding this method mainly concerning the possible harmful and in the long-term even carcinogenic effects of biliopancreaticoduodenal reflux in the gastric pouch
Comment
Several thousands MGBs performed over 15 yrsEasier safer faster amp more effective than
RYGBEasier to revise amp reverse
Controversy regarding carcinogenic effect of BPD reflux
1306
1213
1294
1218
131
1207
114
116
118
12
122
124
126
128
13
132
Before After
BGB LGB MGB
Hemoglobin
RYGB VS Banded RYGB VS OAGBMGB
CHOICE OF PROCEDURE
399
372
394
36
396
352
32
33
34
35
36
37
38
39
4
41
Before After
BGB LGB MGB
Albumin661
644
693
67
685
607
56
58
6
62
64
66
68
7
Before After
BGB LGB MGB
Protein
RYGB VS Banded RYGB VS OAGBMGB
CHOICE OF PROCEDURE
911
87
906
873
909
833
78
8
82
84
86
88
9
92
Before After
BGB LGB MGB
Calcium
CHOICE OF PROCEDURE
RYGB VS Banded RYGB VS OAGBMGB
COMPARISON OF BGBP OAGB VS STD GBP
Outcome after the operations BGBP OAGBP STD GBP
Av Initial weight loss 1-3yrs gt77 gt77 65-70
Weight loss 4-10 years 70-77 70-77 55-65
Resolution of T2DM 80--85 80-90 60-80
VomitingSolid Food Intolerance 5-15 lt5 lt5
Diarrhea and Steatorrhea 1-2A 15-30 NA
Symptomatic Reflux 1-3 3-11 1-3
Marginal Ulcers 3-5 3-5 3-5
Protein Caloric Malnutrition lt1 3-11 lt1
Significant Weight regain 3-10 3-10 10-35
Ringband Erosion 0-1 NA NA
CHOICE OF PROCEDURE
We have enough information currently to enhance the outcome and minimize the risk by matching the operation to the patient
That is the basis forAn Algorithm for Bariatric Metabolic Operations
CHOOSING THE BEST BARIATRIC METABOLIC PROCEDURE FOR THE PATIENT
CHOICE OF PROCEDURE
bull All agesbull With no diabetesbull With low BMI preferably lt40bull With no GERDbull With HO PUDbull With HO or findings of liver diseasebull With Inflammatory bowel diseasebull With dense adhesions from multiple small bowel surgeriesbull Without HO VTEbull In heavy smokers who are not likely to quitbull In gastric cancer endemic areasbull High Risk needing minimal anesthesia and OR timebull High BMI gt 60 as part of a two stage approach
ALGORITHM
LSG BSG
CHOICE OF PROCEDURE
Laparoscopic Sleeve Gastrectomy Or Banded Sleeve Gastrostomy (SGBSD) Indicated for Patients
-All ages-Patients with T2DM lt5years and HbA1-c lt8 C-Peptidegt2 and not on insulin
-Patients with GERD
-ALL BMI ----- -BGBPBMIlt50-- LGBP
Vegetarian (BGBP)
BGBPLGBP
CHOICE OF PROCEDURE
ALGORITHM
Laparoscopic Gastric Bypass(LGBP) or Banded Gastric Bypass(BGBP) Indicated for Patients
bull With Diabetes gt5 years HbA1cgt8 C-Peptide lt2andor on Insulinbull All agesbull All BMI particularly High BMI-gt50bull High risk patients with need for short anesthesia timebull Because it is an easy to perform procedurebull Best tolerated by non Vegetarian
bull GERD Is a contraindicationbull Liver disease is a contraindication
Must be able to follow up patient regularlyPatient must be able to afford the required supplements OAGB
CHOICE OF PROCEDURE
ALGORITHM
OAGBMGB for patients
Sleeve gastrectomy with duodenal bypass(SGDJB) in patients with indication for Gastric Bypass in Gastric Cancer Endemic Areas
As effective as GBPSame weight loss andmetabolic effects as gastric bypass
SG-DJB
CHOICE OF PROCEDURE
ALGORITHM
Sleeve gastrectomy with duodenal bypass(SGDJB) in patients
1Second stage operation for the sleeve gastrectomy
2 Non responders or complications of sleeve gastric bypass or OAGBMGB
BPD-DS SADI SASI SG with enteral bypass
CHOICE OF PROCEDURE
ALGORITHM
BPD-DS SADI SAGI SASI) Indicated for
Areas with high incidence of anemia and very strict vegetarian food habits
CHOICE OF PROCEDURE
ALGORITHM
Sleeve Gastrectomy with gastro-jejunal gastro-ileal or entero-enteral anastomosis
Intra Gastric Balloon ENDOBARRIER
V-BLOC Aspire AssistEndoscopic Plication
For a patient who does not want an intra abdominal gastro-intestinal procedure
CHOICE OF PROCEDURE
Should You Do A Bariatric Metabolic Operation Because That Is What The Patient Wantsrdquo
NOYESmdashIt depends HoweverA bariatric metabolic surgeon should be able to offer the best operation for the patient based on the patientrsquos profile It is good practice to refer the patient to a tertiary center if the surgeon does not offer the operation that meets the patients indication
CHOICE OF PROCEDURE
CHOOSING THE BEST BARIATRIC METABOLIC PROCEDURE FOR THE PATIENT
CHOICE OF PROCEDURE
Case 157 yo Male BMI 57KgM2 T2DM GERD Strict Vegetarian
Algorithm
Gastric bypass-----Preferably Banded gastric bypassmdash------GERD Vegetarian
Not Sleeve because of T2DM GERD and High BMI
Not OAGBMGB because of GERD and probable of protein deficiency
CHOOSING THE BEST BARIATRIC METABOLIC PROCEDURE FOR THE PATIENT
CHOICE OF PROCEDURE
Case 1128 y0 F BMI 42 PCO DUB OSA and HO Migraine headaches
AlgorithmSleeve GastrectomymdashPreferably a Ring banded Sleeve gastrectomy
----No T2DM---No GERDNot Gastric bypass mdash anemia smelly flatus
Not OAGBMGB----Anemia Foul smelling flatus and body odor----Protein deficiency
CHOOSING THE BEST BARIATRIC METABOLIC PROCEDURE FOR THE PATIENT
CHOICE OF PROCEDURE
Case 11137 yo Male BMI 68 OSA OA and a non vegetarian who works at your hospitalReferred by the pulmonologist at your medical Centre
Algorithm
OAGBMGBmdashHigh BMI Non Veg-better food tolerance patient very likely to be followedand to afford the supplements because of proximity to your center
Not sleeve---poor weight loss with sleeve in super obeseNot Banded sleeve---Good weight loss but poor food tolerance since patient is a non vegetarianNot Gastric bypass---Weight loss in super obese have high non response after gastric bypass
and the gastric bypass is technically a more difficult operation than the OAGBNot Banded gastric bypass ndashGood weight loss but a BGBP is a more difficult operation and
the patient will have some food intolerance because of the ring
SURGICAL TREATMENT OPTIONS
At Mohak we perform these standard three operations and their banded modifications
Sleeve Gastrectomy Gastric Bypass OAGBMGB
CHOICE OF PROCEDURE
Evidence based operations performed at MBRSC From 2010 t0 2017---Standardized OperationsLaparoscopic Sleeve Gastrectomybull 90-120 cc Sleevebull 2-5cm from pylorusbull Where a sleeve is indicated but a band is contraindicated or not affordableBanded Sleeve Gastrectomy (BSG) 84 EWL after 60 monthsbull 90-120 cc Sleevebull 2-5cm from pylorusbull Ring 65-75 cmbull At 3-6 cm below GE junctionBanded Gastric bypass (BGBP) 75 EWL 48 monthsbull Create 6mdash7cm long pouchbull 65-75 cm ring at 3-5 cm below GE junction and gt2cm above anastomosisbull Large Gastroenterostomy gt 2cm bull 100cm Roux Limb and 80 cm BP limb for BMIlt50bull 100cm Roux Limb and 150 cm BP limb for BMIgt50Mini-Gastric Bypass (MGB) (OAGB) 79 EWL 60 monthsbull 9-18cm long pouch ~25cm widebull BP Limb length of 180cm BMIlt50Banded Mini-Gastric Bypass(BMGB)(BOAGB)bull 9-18cm long pouch ~25cm widebull Ring 7-75 cmbull BP Limb length of 180cm BMI50
THE MOHAK PROTOCOLStandardized Bariatric and Robotic Surgery Operations
CHOICE OF PROCEDURE
Sleeve Gastrectomy (LSG) or Banded Sleeve Gastrectomy (BSG)bull Non-diabeticsbull No hiatal hernia or GERDbull HO Smokingbull HO alcohol usebull HO PUDbull Abnormal LFTs NASH and early Cirrhosisbull Pts from areas with high incidence of gastric cancer of H pylori infectionbull High risks patients and super obese patients as part of a two-staged operation
Gastric Bypass (LGBP) or Banded Gastric Bypass (BGBP) or Hybrid BGBPMGBbull Have T2DM with HgbA1c lt 8 and duration lt 5 yearsbull Have Hiatal hernia or GERDbull Are Vegetarianbull No nicotine addiction (smoking)bull Have HO Alcohol intake bull Have NASH at surgery-No cirrhosisbull Not likely to come back for follow up andbull Revision operation of Failed Sleeve gastrectomy GBP or MGB
MOHAK ALGORITHM
CHOICE OF PROCEDURE
One Anastomosis Gastric Bypass-Mini-Gastric Bypass (OAGBP-MGB) bull Have T2DM with HgbA1c 8 and durationgt5 yearsbull Have No GERDbull Are Non-vegetarianbull Have poor dentitionbull Most likely to return for follow up at the clinicbull No HO alcohol intakebull No Nicotine addiction (smoking)bull Normal LFTsbull No NASH at surgery or cirrhosisbull Commitment by our program to have 100 follow up of theses patient
Revision Operationbull Sleeve to Banded RY with 100 cm Al limb and 180 cm BP Limbbull MGB to diverted MGB for Reflux Existing BPL and 100cm ALbull MGB to GBP for PCM or reversal to normal anatomy for PCMmdashinterim gastrostomy feedingbull GBP to BGBP with 180cm BP limb for Weight regain or inadequate weight loss BMIlt40bull GBP to BGBP with 300cm common limb for Weight regain or inadequate weight loss BMIgt40
MOHAK ALGORITHM
CHOICE OF PROCEDURE
bull Laparoscopic Gastric Bypass
bull Laparoscopic Sleeve Gastrectomy
bull Divided Mini-Gastric Bypass
bull Biliopancreatic Diversion with DS
bull Single Anastomosis Duodeno-ileostomy
bull Gastric Plication
bull Banded Gastric Plication
bull Endoscopic Gastroplasty
bull Laparoscopic Adjustable Gastric bands
bull Balloon Implantation
bull Ileal interposition
These other operations will be used selectively based on patients needs and the surgeons determination
CHOICE OF PROCEDURE
The MOHAK Guide for Choice of Bariatric Metabolic Surgery Operations
Single Incision Laparoscopic Robotic and Endoscopic approaches are
available at patientsrsquo requests and the discretion of the surgeon
CHOICE OF PROCEDURE
The MOHAK Guide for Choice of Bariatric Metabolic Surgery Operations
Mohak Bariatrics and Robotics Surgery Center Motto
ldquoThe best operation for the patient by a competent surgeon in a well equipped hospital to maximize outcomes with the least amount of risks exposurerdquo
WE ARE ABLE TO CHOOSE THE BEST BARIATRIC METABOLIC PROCEDURE FOR YOUR PATIENT
Good long-term results are our marketing toolSuccessful patients make a lot of referralsbull
CHOICE OF PROCEDURE
The MOHAK Guide for Choice of Bariatric Metabolic Surgery Operations
We offer various treatment modalities for obesity The operation is
determined by the profile of the patient and guided by findings from
analysis of the data from our prospectively maintained database
MOHAK TEAM INDORE INDIA
THANK YOU
MECHANISMS OF ACTION OF VARIOUS BARIATRIC METABOLIC OPERATIONS
bull Restrictive Effect Control the reservoir size
bull Neural Stimulation of G-E full sense effectsatiation
bull Patient Compliance Forced behavior modification Motivation fear dyspepsia physical activity dietary habit alteration support group participation and physician contact
bull Malabsorptive Effect Bypassed segment of the GI tract results in mal absorption
bull Dumping Effect High caloric fluid and fatty food intolerance
bull Ghrelin Effect Anorexia
bull Foregut effect GIP PYY and Leptin effects
bull Hindgut effect GLP-I motilityNauseasatiation
bull Microbiota effect alteration of the bacterial flora of the gut alters absorption
bull Bile salts
CHOICE OF PROCEDURE
Currently known mechanisms responsible for the effects of the various bariatric metabolic operations include but not limited to
Outcomes of the various operationsWeight Loss and maintenanceResolution of co-morbid conditions---Contra-indications to the various operations--Complications inherent in the operations----
CHOICE OF PROCEDURE
bull Refluxbull Ulcersbull Nutrient deficienciesbull Protein caloric malnutritionbull DiarrheaSteatorrheabull Food Intolerancebull RingBand Migration
The Operations and Procedures
SURGICAL TREATMENT OPTIONS
A Bariatric Metabolic Surgeon should be able to Perform these three basic procedures and their modifications
Sleeve Gastrectomy Gastric Bypass OAGBMGB
CHOICE OF PROCEDURE
CHOICE OF PROCEDURE
Sleeve Gastrectomy Ring BandedSleeve Gastrectomy
The Ring Stabilizes The Size of The Sleeveand minimizes the disadvantagesSEEVE GASTRECTOMY
1 Relatively simple operation2 No disruption of gastrointestinal tract3 No gastro-intestinal anastomosis4 Nearly regular intestinal absorption 5 Low incidence of dumping syndrome6 0 risk of developing an internal hernia 7 Good weight loss and resolution of
co-morbid conditions almost equal to GBP
Disadvantages-Weight loss ltLGBP-Dilation of sleeve with weight regain and recurrence of co-morbid conditions
-Neo-reflux-Intractable leaks-Torsionstenosis-Porto-mesenteric thrombosis
CHOICE OF PROCEDURE
Sleeve Gastrectomy
Ring BandedSleeve Gastrectomy
06M 1 yr 2yr 3yr 4yr 5yr 6yr
EB
WL
Follow UP
p vs Baseline always lt0001 BSG LSG
Bhandari M Mathur W etal In Print SOARD
CHOICE OF PROCEDURE
THREE YEARS SIX YEARS
THREE YEARS SIX YEARSLess than 50 50-75 above75 Less than 50 50-75 above75
BSG (0) 0 (2) 35 (56) 965 (0) 0 (4) 83 (44) 917
LSG (15)111 (66)474 (53)395 (46)469 (46)469 (9)91
0102030405060708090
100
BSG
LSG
3 YEARSLSG 111BSG 0
FAILURE RATE
6 YEARSLSG 469BSG 0
CHOICE OF PROCEDURE
CHOICE OF PROCEDURE
Bhandari M Mathur W Mishra A MBRSC Course May 2017 Indore India
The Gastric Bypass is the Gold Standard of Bariatric Metabolic Operations
RGBP BGBP
CHOICE OF PROCEDURE
COMPARISON OF BGBP VS STD GBP
Outcome after the operations BGBP STD GBP
Av Initial weight loss 1-3yrs gt77 65-70
Weight loss 4-10 years 70-77 55-65
Resolution of T2DM 80--85 60-80
VomitingSolid Food Intolerance 5-15 lt5
Significant Weight regain 3-7 10-35
Ringband Erosion 0-2 NA
CHOICE OF PROCEDURE
OAGBPMGB
One Anastamosis Gastric BypassMini Gastric Bypass (OAGBMGB)
Simplicity
Repeatability
Minimal Dissection
Reversibility
Exit Strategy
Safety
Minimal Suturing
Short Duration
Short Learning Curve
CHOICE OF PROCEDURE
OAGBSAGBMGB Advantagesbull Easier operation compared to Standard GBPbull Better food tolerancebull More weight loss than standard GBPbull Better weigh Loss Maintenancebull Higher metabolic effect on T2DM and Hyperlipidemiabull Less incidence of internal herniabull More options for revision if needed
Disadvantagesbull Bile reflux gastritis and esophagitisbull Marginal ulcersbull Nutrient deficienciesbull Protein Caloric Malnutrition
Quan Y Huanh A Ye M Efficacy of laproscopic mini gastric bypass for obesity and type 2 diabetes mellitus A systematic review and met-analysis Gastroenterol Res Pract 2015 ID 152852 10155
CHOICE OF PROCEDURE
2015 ndash Review articleVictorzon M et al Scand J Surg 2015 Mar104(1)48-53 Single-anastomosis gastric
bypass better faster and safer
bull The abstracts of 73 articles were reviewed and after removal of case studies duplicates and irrelevant articles 10 articles remained for closer review
bull Several thousand of this operation have been performed for more than 15 years It is claimed to be an easier safer faster and more effective metabolic operation compared to the standard Roux-en-Y gastric bypass The proponents of this operation also claim that this operation is easier to revise and reverse leaving more options compared to the situation after standard bypass in case of failure However there is much controversy surrounding this method mainly concerning the possible harmful and in the long-term even carcinogenic effects of biliopancreaticoduodenal reflux in the gastric pouch
Comment
Several thousands MGBs performed over 15 yrsEasier safer faster amp more effective than
RYGBEasier to revise amp reverse
Controversy regarding carcinogenic effect of BPD reflux
1306
1213
1294
1218
131
1207
114
116
118
12
122
124
126
128
13
132
Before After
BGB LGB MGB
Hemoglobin
RYGB VS Banded RYGB VS OAGBMGB
CHOICE OF PROCEDURE
399
372
394
36
396
352
32
33
34
35
36
37
38
39
4
41
Before After
BGB LGB MGB
Albumin661
644
693
67
685
607
56
58
6
62
64
66
68
7
Before After
BGB LGB MGB
Protein
RYGB VS Banded RYGB VS OAGBMGB
CHOICE OF PROCEDURE
911
87
906
873
909
833
78
8
82
84
86
88
9
92
Before After
BGB LGB MGB
Calcium
CHOICE OF PROCEDURE
RYGB VS Banded RYGB VS OAGBMGB
COMPARISON OF BGBP OAGB VS STD GBP
Outcome after the operations BGBP OAGBP STD GBP
Av Initial weight loss 1-3yrs gt77 gt77 65-70
Weight loss 4-10 years 70-77 70-77 55-65
Resolution of T2DM 80--85 80-90 60-80
VomitingSolid Food Intolerance 5-15 lt5 lt5
Diarrhea and Steatorrhea 1-2A 15-30 NA
Symptomatic Reflux 1-3 3-11 1-3
Marginal Ulcers 3-5 3-5 3-5
Protein Caloric Malnutrition lt1 3-11 lt1
Significant Weight regain 3-10 3-10 10-35
Ringband Erosion 0-1 NA NA
CHOICE OF PROCEDURE
We have enough information currently to enhance the outcome and minimize the risk by matching the operation to the patient
That is the basis forAn Algorithm for Bariatric Metabolic Operations
CHOOSING THE BEST BARIATRIC METABOLIC PROCEDURE FOR THE PATIENT
CHOICE OF PROCEDURE
bull All agesbull With no diabetesbull With low BMI preferably lt40bull With no GERDbull With HO PUDbull With HO or findings of liver diseasebull With Inflammatory bowel diseasebull With dense adhesions from multiple small bowel surgeriesbull Without HO VTEbull In heavy smokers who are not likely to quitbull In gastric cancer endemic areasbull High Risk needing minimal anesthesia and OR timebull High BMI gt 60 as part of a two stage approach
ALGORITHM
LSG BSG
CHOICE OF PROCEDURE
Laparoscopic Sleeve Gastrectomy Or Banded Sleeve Gastrostomy (SGBSD) Indicated for Patients
-All ages-Patients with T2DM lt5years and HbA1-c lt8 C-Peptidegt2 and not on insulin
-Patients with GERD
-ALL BMI ----- -BGBPBMIlt50-- LGBP
Vegetarian (BGBP)
BGBPLGBP
CHOICE OF PROCEDURE
ALGORITHM
Laparoscopic Gastric Bypass(LGBP) or Banded Gastric Bypass(BGBP) Indicated for Patients
bull With Diabetes gt5 years HbA1cgt8 C-Peptide lt2andor on Insulinbull All agesbull All BMI particularly High BMI-gt50bull High risk patients with need for short anesthesia timebull Because it is an easy to perform procedurebull Best tolerated by non Vegetarian
bull GERD Is a contraindicationbull Liver disease is a contraindication
Must be able to follow up patient regularlyPatient must be able to afford the required supplements OAGB
CHOICE OF PROCEDURE
ALGORITHM
OAGBMGB for patients
Sleeve gastrectomy with duodenal bypass(SGDJB) in patients with indication for Gastric Bypass in Gastric Cancer Endemic Areas
As effective as GBPSame weight loss andmetabolic effects as gastric bypass
SG-DJB
CHOICE OF PROCEDURE
ALGORITHM
Sleeve gastrectomy with duodenal bypass(SGDJB) in patients
1Second stage operation for the sleeve gastrectomy
2 Non responders or complications of sleeve gastric bypass or OAGBMGB
BPD-DS SADI SASI SG with enteral bypass
CHOICE OF PROCEDURE
ALGORITHM
BPD-DS SADI SAGI SASI) Indicated for
Areas with high incidence of anemia and very strict vegetarian food habits
CHOICE OF PROCEDURE
ALGORITHM
Sleeve Gastrectomy with gastro-jejunal gastro-ileal or entero-enteral anastomosis
Intra Gastric Balloon ENDOBARRIER
V-BLOC Aspire AssistEndoscopic Plication
For a patient who does not want an intra abdominal gastro-intestinal procedure
CHOICE OF PROCEDURE
Should You Do A Bariatric Metabolic Operation Because That Is What The Patient Wantsrdquo
NOYESmdashIt depends HoweverA bariatric metabolic surgeon should be able to offer the best operation for the patient based on the patientrsquos profile It is good practice to refer the patient to a tertiary center if the surgeon does not offer the operation that meets the patients indication
CHOICE OF PROCEDURE
CHOOSING THE BEST BARIATRIC METABOLIC PROCEDURE FOR THE PATIENT
CHOICE OF PROCEDURE
Case 157 yo Male BMI 57KgM2 T2DM GERD Strict Vegetarian
Algorithm
Gastric bypass-----Preferably Banded gastric bypassmdash------GERD Vegetarian
Not Sleeve because of T2DM GERD and High BMI
Not OAGBMGB because of GERD and probable of protein deficiency
CHOOSING THE BEST BARIATRIC METABOLIC PROCEDURE FOR THE PATIENT
CHOICE OF PROCEDURE
Case 1128 y0 F BMI 42 PCO DUB OSA and HO Migraine headaches
AlgorithmSleeve GastrectomymdashPreferably a Ring banded Sleeve gastrectomy
----No T2DM---No GERDNot Gastric bypass mdash anemia smelly flatus
Not OAGBMGB----Anemia Foul smelling flatus and body odor----Protein deficiency
CHOOSING THE BEST BARIATRIC METABOLIC PROCEDURE FOR THE PATIENT
CHOICE OF PROCEDURE
Case 11137 yo Male BMI 68 OSA OA and a non vegetarian who works at your hospitalReferred by the pulmonologist at your medical Centre
Algorithm
OAGBMGBmdashHigh BMI Non Veg-better food tolerance patient very likely to be followedand to afford the supplements because of proximity to your center
Not sleeve---poor weight loss with sleeve in super obeseNot Banded sleeve---Good weight loss but poor food tolerance since patient is a non vegetarianNot Gastric bypass---Weight loss in super obese have high non response after gastric bypass
and the gastric bypass is technically a more difficult operation than the OAGBNot Banded gastric bypass ndashGood weight loss but a BGBP is a more difficult operation and
the patient will have some food intolerance because of the ring
SURGICAL TREATMENT OPTIONS
At Mohak we perform these standard three operations and their banded modifications
Sleeve Gastrectomy Gastric Bypass OAGBMGB
CHOICE OF PROCEDURE
Evidence based operations performed at MBRSC From 2010 t0 2017---Standardized OperationsLaparoscopic Sleeve Gastrectomybull 90-120 cc Sleevebull 2-5cm from pylorusbull Where a sleeve is indicated but a band is contraindicated or not affordableBanded Sleeve Gastrectomy (BSG) 84 EWL after 60 monthsbull 90-120 cc Sleevebull 2-5cm from pylorusbull Ring 65-75 cmbull At 3-6 cm below GE junctionBanded Gastric bypass (BGBP) 75 EWL 48 monthsbull Create 6mdash7cm long pouchbull 65-75 cm ring at 3-5 cm below GE junction and gt2cm above anastomosisbull Large Gastroenterostomy gt 2cm bull 100cm Roux Limb and 80 cm BP limb for BMIlt50bull 100cm Roux Limb and 150 cm BP limb for BMIgt50Mini-Gastric Bypass (MGB) (OAGB) 79 EWL 60 monthsbull 9-18cm long pouch ~25cm widebull BP Limb length of 180cm BMIlt50Banded Mini-Gastric Bypass(BMGB)(BOAGB)bull 9-18cm long pouch ~25cm widebull Ring 7-75 cmbull BP Limb length of 180cm BMI50
THE MOHAK PROTOCOLStandardized Bariatric and Robotic Surgery Operations
CHOICE OF PROCEDURE
Sleeve Gastrectomy (LSG) or Banded Sleeve Gastrectomy (BSG)bull Non-diabeticsbull No hiatal hernia or GERDbull HO Smokingbull HO alcohol usebull HO PUDbull Abnormal LFTs NASH and early Cirrhosisbull Pts from areas with high incidence of gastric cancer of H pylori infectionbull High risks patients and super obese patients as part of a two-staged operation
Gastric Bypass (LGBP) or Banded Gastric Bypass (BGBP) or Hybrid BGBPMGBbull Have T2DM with HgbA1c lt 8 and duration lt 5 yearsbull Have Hiatal hernia or GERDbull Are Vegetarianbull No nicotine addiction (smoking)bull Have HO Alcohol intake bull Have NASH at surgery-No cirrhosisbull Not likely to come back for follow up andbull Revision operation of Failed Sleeve gastrectomy GBP or MGB
MOHAK ALGORITHM
CHOICE OF PROCEDURE
One Anastomosis Gastric Bypass-Mini-Gastric Bypass (OAGBP-MGB) bull Have T2DM with HgbA1c 8 and durationgt5 yearsbull Have No GERDbull Are Non-vegetarianbull Have poor dentitionbull Most likely to return for follow up at the clinicbull No HO alcohol intakebull No Nicotine addiction (smoking)bull Normal LFTsbull No NASH at surgery or cirrhosisbull Commitment by our program to have 100 follow up of theses patient
Revision Operationbull Sleeve to Banded RY with 100 cm Al limb and 180 cm BP Limbbull MGB to diverted MGB for Reflux Existing BPL and 100cm ALbull MGB to GBP for PCM or reversal to normal anatomy for PCMmdashinterim gastrostomy feedingbull GBP to BGBP with 180cm BP limb for Weight regain or inadequate weight loss BMIlt40bull GBP to BGBP with 300cm common limb for Weight regain or inadequate weight loss BMIgt40
MOHAK ALGORITHM
CHOICE OF PROCEDURE
bull Laparoscopic Gastric Bypass
bull Laparoscopic Sleeve Gastrectomy
bull Divided Mini-Gastric Bypass
bull Biliopancreatic Diversion with DS
bull Single Anastomosis Duodeno-ileostomy
bull Gastric Plication
bull Banded Gastric Plication
bull Endoscopic Gastroplasty
bull Laparoscopic Adjustable Gastric bands
bull Balloon Implantation
bull Ileal interposition
These other operations will be used selectively based on patients needs and the surgeons determination
CHOICE OF PROCEDURE
The MOHAK Guide for Choice of Bariatric Metabolic Surgery Operations
Single Incision Laparoscopic Robotic and Endoscopic approaches are
available at patientsrsquo requests and the discretion of the surgeon
CHOICE OF PROCEDURE
The MOHAK Guide for Choice of Bariatric Metabolic Surgery Operations
Mohak Bariatrics and Robotics Surgery Center Motto
ldquoThe best operation for the patient by a competent surgeon in a well equipped hospital to maximize outcomes with the least amount of risks exposurerdquo
WE ARE ABLE TO CHOOSE THE BEST BARIATRIC METABOLIC PROCEDURE FOR YOUR PATIENT
Good long-term results are our marketing toolSuccessful patients make a lot of referralsbull
CHOICE OF PROCEDURE
The MOHAK Guide for Choice of Bariatric Metabolic Surgery Operations
We offer various treatment modalities for obesity The operation is
determined by the profile of the patient and guided by findings from
analysis of the data from our prospectively maintained database
MOHAK TEAM INDORE INDIA
THANK YOU
Outcomes of the various operationsWeight Loss and maintenanceResolution of co-morbid conditions---Contra-indications to the various operations--Complications inherent in the operations----
CHOICE OF PROCEDURE
bull Refluxbull Ulcersbull Nutrient deficienciesbull Protein caloric malnutritionbull DiarrheaSteatorrheabull Food Intolerancebull RingBand Migration
The Operations and Procedures
SURGICAL TREATMENT OPTIONS
A Bariatric Metabolic Surgeon should be able to Perform these three basic procedures and their modifications
Sleeve Gastrectomy Gastric Bypass OAGBMGB
CHOICE OF PROCEDURE
CHOICE OF PROCEDURE
Sleeve Gastrectomy Ring BandedSleeve Gastrectomy
The Ring Stabilizes The Size of The Sleeveand minimizes the disadvantagesSEEVE GASTRECTOMY
1 Relatively simple operation2 No disruption of gastrointestinal tract3 No gastro-intestinal anastomosis4 Nearly regular intestinal absorption 5 Low incidence of dumping syndrome6 0 risk of developing an internal hernia 7 Good weight loss and resolution of
co-morbid conditions almost equal to GBP
Disadvantages-Weight loss ltLGBP-Dilation of sleeve with weight regain and recurrence of co-morbid conditions
-Neo-reflux-Intractable leaks-Torsionstenosis-Porto-mesenteric thrombosis
CHOICE OF PROCEDURE
Sleeve Gastrectomy
Ring BandedSleeve Gastrectomy
06M 1 yr 2yr 3yr 4yr 5yr 6yr
EB
WL
Follow UP
p vs Baseline always lt0001 BSG LSG
Bhandari M Mathur W etal In Print SOARD
CHOICE OF PROCEDURE
THREE YEARS SIX YEARS
THREE YEARS SIX YEARSLess than 50 50-75 above75 Less than 50 50-75 above75
BSG (0) 0 (2) 35 (56) 965 (0) 0 (4) 83 (44) 917
LSG (15)111 (66)474 (53)395 (46)469 (46)469 (9)91
0102030405060708090
100
BSG
LSG
3 YEARSLSG 111BSG 0
FAILURE RATE
6 YEARSLSG 469BSG 0
CHOICE OF PROCEDURE
CHOICE OF PROCEDURE
Bhandari M Mathur W Mishra A MBRSC Course May 2017 Indore India
The Gastric Bypass is the Gold Standard of Bariatric Metabolic Operations
RGBP BGBP
CHOICE OF PROCEDURE
COMPARISON OF BGBP VS STD GBP
Outcome after the operations BGBP STD GBP
Av Initial weight loss 1-3yrs gt77 65-70
Weight loss 4-10 years 70-77 55-65
Resolution of T2DM 80--85 60-80
VomitingSolid Food Intolerance 5-15 lt5
Significant Weight regain 3-7 10-35
Ringband Erosion 0-2 NA
CHOICE OF PROCEDURE
OAGBPMGB
One Anastamosis Gastric BypassMini Gastric Bypass (OAGBMGB)
Simplicity
Repeatability
Minimal Dissection
Reversibility
Exit Strategy
Safety
Minimal Suturing
Short Duration
Short Learning Curve
CHOICE OF PROCEDURE
OAGBSAGBMGB Advantagesbull Easier operation compared to Standard GBPbull Better food tolerancebull More weight loss than standard GBPbull Better weigh Loss Maintenancebull Higher metabolic effect on T2DM and Hyperlipidemiabull Less incidence of internal herniabull More options for revision if needed
Disadvantagesbull Bile reflux gastritis and esophagitisbull Marginal ulcersbull Nutrient deficienciesbull Protein Caloric Malnutrition
Quan Y Huanh A Ye M Efficacy of laproscopic mini gastric bypass for obesity and type 2 diabetes mellitus A systematic review and met-analysis Gastroenterol Res Pract 2015 ID 152852 10155
CHOICE OF PROCEDURE
2015 ndash Review articleVictorzon M et al Scand J Surg 2015 Mar104(1)48-53 Single-anastomosis gastric
bypass better faster and safer
bull The abstracts of 73 articles were reviewed and after removal of case studies duplicates and irrelevant articles 10 articles remained for closer review
bull Several thousand of this operation have been performed for more than 15 years It is claimed to be an easier safer faster and more effective metabolic operation compared to the standard Roux-en-Y gastric bypass The proponents of this operation also claim that this operation is easier to revise and reverse leaving more options compared to the situation after standard bypass in case of failure However there is much controversy surrounding this method mainly concerning the possible harmful and in the long-term even carcinogenic effects of biliopancreaticoduodenal reflux in the gastric pouch
Comment
Several thousands MGBs performed over 15 yrsEasier safer faster amp more effective than
RYGBEasier to revise amp reverse
Controversy regarding carcinogenic effect of BPD reflux
1306
1213
1294
1218
131
1207
114
116
118
12
122
124
126
128
13
132
Before After
BGB LGB MGB
Hemoglobin
RYGB VS Banded RYGB VS OAGBMGB
CHOICE OF PROCEDURE
399
372
394
36
396
352
32
33
34
35
36
37
38
39
4
41
Before After
BGB LGB MGB
Albumin661
644
693
67
685
607
56
58
6
62
64
66
68
7
Before After
BGB LGB MGB
Protein
RYGB VS Banded RYGB VS OAGBMGB
CHOICE OF PROCEDURE
911
87
906
873
909
833
78
8
82
84
86
88
9
92
Before After
BGB LGB MGB
Calcium
CHOICE OF PROCEDURE
RYGB VS Banded RYGB VS OAGBMGB
COMPARISON OF BGBP OAGB VS STD GBP
Outcome after the operations BGBP OAGBP STD GBP
Av Initial weight loss 1-3yrs gt77 gt77 65-70
Weight loss 4-10 years 70-77 70-77 55-65
Resolution of T2DM 80--85 80-90 60-80
VomitingSolid Food Intolerance 5-15 lt5 lt5
Diarrhea and Steatorrhea 1-2A 15-30 NA
Symptomatic Reflux 1-3 3-11 1-3
Marginal Ulcers 3-5 3-5 3-5
Protein Caloric Malnutrition lt1 3-11 lt1
Significant Weight regain 3-10 3-10 10-35
Ringband Erosion 0-1 NA NA
CHOICE OF PROCEDURE
We have enough information currently to enhance the outcome and minimize the risk by matching the operation to the patient
That is the basis forAn Algorithm for Bariatric Metabolic Operations
CHOOSING THE BEST BARIATRIC METABOLIC PROCEDURE FOR THE PATIENT
CHOICE OF PROCEDURE
bull All agesbull With no diabetesbull With low BMI preferably lt40bull With no GERDbull With HO PUDbull With HO or findings of liver diseasebull With Inflammatory bowel diseasebull With dense adhesions from multiple small bowel surgeriesbull Without HO VTEbull In heavy smokers who are not likely to quitbull In gastric cancer endemic areasbull High Risk needing minimal anesthesia and OR timebull High BMI gt 60 as part of a two stage approach
ALGORITHM
LSG BSG
CHOICE OF PROCEDURE
Laparoscopic Sleeve Gastrectomy Or Banded Sleeve Gastrostomy (SGBSD) Indicated for Patients
-All ages-Patients with T2DM lt5years and HbA1-c lt8 C-Peptidegt2 and not on insulin
-Patients with GERD
-ALL BMI ----- -BGBPBMIlt50-- LGBP
Vegetarian (BGBP)
BGBPLGBP
CHOICE OF PROCEDURE
ALGORITHM
Laparoscopic Gastric Bypass(LGBP) or Banded Gastric Bypass(BGBP) Indicated for Patients
bull With Diabetes gt5 years HbA1cgt8 C-Peptide lt2andor on Insulinbull All agesbull All BMI particularly High BMI-gt50bull High risk patients with need for short anesthesia timebull Because it is an easy to perform procedurebull Best tolerated by non Vegetarian
bull GERD Is a contraindicationbull Liver disease is a contraindication
Must be able to follow up patient regularlyPatient must be able to afford the required supplements OAGB
CHOICE OF PROCEDURE
ALGORITHM
OAGBMGB for patients
Sleeve gastrectomy with duodenal bypass(SGDJB) in patients with indication for Gastric Bypass in Gastric Cancer Endemic Areas
As effective as GBPSame weight loss andmetabolic effects as gastric bypass
SG-DJB
CHOICE OF PROCEDURE
ALGORITHM
Sleeve gastrectomy with duodenal bypass(SGDJB) in patients
1Second stage operation for the sleeve gastrectomy
2 Non responders or complications of sleeve gastric bypass or OAGBMGB
BPD-DS SADI SASI SG with enteral bypass
CHOICE OF PROCEDURE
ALGORITHM
BPD-DS SADI SAGI SASI) Indicated for
Areas with high incidence of anemia and very strict vegetarian food habits
CHOICE OF PROCEDURE
ALGORITHM
Sleeve Gastrectomy with gastro-jejunal gastro-ileal or entero-enteral anastomosis
Intra Gastric Balloon ENDOBARRIER
V-BLOC Aspire AssistEndoscopic Plication
For a patient who does not want an intra abdominal gastro-intestinal procedure
CHOICE OF PROCEDURE
Should You Do A Bariatric Metabolic Operation Because That Is What The Patient Wantsrdquo
NOYESmdashIt depends HoweverA bariatric metabolic surgeon should be able to offer the best operation for the patient based on the patientrsquos profile It is good practice to refer the patient to a tertiary center if the surgeon does not offer the operation that meets the patients indication
CHOICE OF PROCEDURE
CHOOSING THE BEST BARIATRIC METABOLIC PROCEDURE FOR THE PATIENT
CHOICE OF PROCEDURE
Case 157 yo Male BMI 57KgM2 T2DM GERD Strict Vegetarian
Algorithm
Gastric bypass-----Preferably Banded gastric bypassmdash------GERD Vegetarian
Not Sleeve because of T2DM GERD and High BMI
Not OAGBMGB because of GERD and probable of protein deficiency
CHOOSING THE BEST BARIATRIC METABOLIC PROCEDURE FOR THE PATIENT
CHOICE OF PROCEDURE
Case 1128 y0 F BMI 42 PCO DUB OSA and HO Migraine headaches
AlgorithmSleeve GastrectomymdashPreferably a Ring banded Sleeve gastrectomy
----No T2DM---No GERDNot Gastric bypass mdash anemia smelly flatus
Not OAGBMGB----Anemia Foul smelling flatus and body odor----Protein deficiency
CHOOSING THE BEST BARIATRIC METABOLIC PROCEDURE FOR THE PATIENT
CHOICE OF PROCEDURE
Case 11137 yo Male BMI 68 OSA OA and a non vegetarian who works at your hospitalReferred by the pulmonologist at your medical Centre
Algorithm
OAGBMGBmdashHigh BMI Non Veg-better food tolerance patient very likely to be followedand to afford the supplements because of proximity to your center
Not sleeve---poor weight loss with sleeve in super obeseNot Banded sleeve---Good weight loss but poor food tolerance since patient is a non vegetarianNot Gastric bypass---Weight loss in super obese have high non response after gastric bypass
and the gastric bypass is technically a more difficult operation than the OAGBNot Banded gastric bypass ndashGood weight loss but a BGBP is a more difficult operation and
the patient will have some food intolerance because of the ring
SURGICAL TREATMENT OPTIONS
At Mohak we perform these standard three operations and their banded modifications
Sleeve Gastrectomy Gastric Bypass OAGBMGB
CHOICE OF PROCEDURE
Evidence based operations performed at MBRSC From 2010 t0 2017---Standardized OperationsLaparoscopic Sleeve Gastrectomybull 90-120 cc Sleevebull 2-5cm from pylorusbull Where a sleeve is indicated but a band is contraindicated or not affordableBanded Sleeve Gastrectomy (BSG) 84 EWL after 60 monthsbull 90-120 cc Sleevebull 2-5cm from pylorusbull Ring 65-75 cmbull At 3-6 cm below GE junctionBanded Gastric bypass (BGBP) 75 EWL 48 monthsbull Create 6mdash7cm long pouchbull 65-75 cm ring at 3-5 cm below GE junction and gt2cm above anastomosisbull Large Gastroenterostomy gt 2cm bull 100cm Roux Limb and 80 cm BP limb for BMIlt50bull 100cm Roux Limb and 150 cm BP limb for BMIgt50Mini-Gastric Bypass (MGB) (OAGB) 79 EWL 60 monthsbull 9-18cm long pouch ~25cm widebull BP Limb length of 180cm BMIlt50Banded Mini-Gastric Bypass(BMGB)(BOAGB)bull 9-18cm long pouch ~25cm widebull Ring 7-75 cmbull BP Limb length of 180cm BMI50
THE MOHAK PROTOCOLStandardized Bariatric and Robotic Surgery Operations
CHOICE OF PROCEDURE
Sleeve Gastrectomy (LSG) or Banded Sleeve Gastrectomy (BSG)bull Non-diabeticsbull No hiatal hernia or GERDbull HO Smokingbull HO alcohol usebull HO PUDbull Abnormal LFTs NASH and early Cirrhosisbull Pts from areas with high incidence of gastric cancer of H pylori infectionbull High risks patients and super obese patients as part of a two-staged operation
Gastric Bypass (LGBP) or Banded Gastric Bypass (BGBP) or Hybrid BGBPMGBbull Have T2DM with HgbA1c lt 8 and duration lt 5 yearsbull Have Hiatal hernia or GERDbull Are Vegetarianbull No nicotine addiction (smoking)bull Have HO Alcohol intake bull Have NASH at surgery-No cirrhosisbull Not likely to come back for follow up andbull Revision operation of Failed Sleeve gastrectomy GBP or MGB
MOHAK ALGORITHM
CHOICE OF PROCEDURE
One Anastomosis Gastric Bypass-Mini-Gastric Bypass (OAGBP-MGB) bull Have T2DM with HgbA1c 8 and durationgt5 yearsbull Have No GERDbull Are Non-vegetarianbull Have poor dentitionbull Most likely to return for follow up at the clinicbull No HO alcohol intakebull No Nicotine addiction (smoking)bull Normal LFTsbull No NASH at surgery or cirrhosisbull Commitment by our program to have 100 follow up of theses patient
Revision Operationbull Sleeve to Banded RY with 100 cm Al limb and 180 cm BP Limbbull MGB to diverted MGB for Reflux Existing BPL and 100cm ALbull MGB to GBP for PCM or reversal to normal anatomy for PCMmdashinterim gastrostomy feedingbull GBP to BGBP with 180cm BP limb for Weight regain or inadequate weight loss BMIlt40bull GBP to BGBP with 300cm common limb for Weight regain or inadequate weight loss BMIgt40
MOHAK ALGORITHM
CHOICE OF PROCEDURE
bull Laparoscopic Gastric Bypass
bull Laparoscopic Sleeve Gastrectomy
bull Divided Mini-Gastric Bypass
bull Biliopancreatic Diversion with DS
bull Single Anastomosis Duodeno-ileostomy
bull Gastric Plication
bull Banded Gastric Plication
bull Endoscopic Gastroplasty
bull Laparoscopic Adjustable Gastric bands
bull Balloon Implantation
bull Ileal interposition
These other operations will be used selectively based on patients needs and the surgeons determination
CHOICE OF PROCEDURE
The MOHAK Guide for Choice of Bariatric Metabolic Surgery Operations
Single Incision Laparoscopic Robotic and Endoscopic approaches are
available at patientsrsquo requests and the discretion of the surgeon
CHOICE OF PROCEDURE
The MOHAK Guide for Choice of Bariatric Metabolic Surgery Operations
Mohak Bariatrics and Robotics Surgery Center Motto
ldquoThe best operation for the patient by a competent surgeon in a well equipped hospital to maximize outcomes with the least amount of risks exposurerdquo
WE ARE ABLE TO CHOOSE THE BEST BARIATRIC METABOLIC PROCEDURE FOR YOUR PATIENT
Good long-term results are our marketing toolSuccessful patients make a lot of referralsbull
CHOICE OF PROCEDURE
The MOHAK Guide for Choice of Bariatric Metabolic Surgery Operations
We offer various treatment modalities for obesity The operation is
determined by the profile of the patient and guided by findings from
analysis of the data from our prospectively maintained database
MOHAK TEAM INDORE INDIA
THANK YOU
SURGICAL TREATMENT OPTIONS
A Bariatric Metabolic Surgeon should be able to Perform these three basic procedures and their modifications
Sleeve Gastrectomy Gastric Bypass OAGBMGB
CHOICE OF PROCEDURE
CHOICE OF PROCEDURE
Sleeve Gastrectomy Ring BandedSleeve Gastrectomy
The Ring Stabilizes The Size of The Sleeveand minimizes the disadvantagesSEEVE GASTRECTOMY
1 Relatively simple operation2 No disruption of gastrointestinal tract3 No gastro-intestinal anastomosis4 Nearly regular intestinal absorption 5 Low incidence of dumping syndrome6 0 risk of developing an internal hernia 7 Good weight loss and resolution of
co-morbid conditions almost equal to GBP
Disadvantages-Weight loss ltLGBP-Dilation of sleeve with weight regain and recurrence of co-morbid conditions
-Neo-reflux-Intractable leaks-Torsionstenosis-Porto-mesenteric thrombosis
CHOICE OF PROCEDURE
Sleeve Gastrectomy
Ring BandedSleeve Gastrectomy
06M 1 yr 2yr 3yr 4yr 5yr 6yr
EB
WL
Follow UP
p vs Baseline always lt0001 BSG LSG
Bhandari M Mathur W etal In Print SOARD
CHOICE OF PROCEDURE
THREE YEARS SIX YEARS
THREE YEARS SIX YEARSLess than 50 50-75 above75 Less than 50 50-75 above75
BSG (0) 0 (2) 35 (56) 965 (0) 0 (4) 83 (44) 917
LSG (15)111 (66)474 (53)395 (46)469 (46)469 (9)91
0102030405060708090
100
BSG
LSG
3 YEARSLSG 111BSG 0
FAILURE RATE
6 YEARSLSG 469BSG 0
CHOICE OF PROCEDURE
CHOICE OF PROCEDURE
Bhandari M Mathur W Mishra A MBRSC Course May 2017 Indore India
The Gastric Bypass is the Gold Standard of Bariatric Metabolic Operations
RGBP BGBP
CHOICE OF PROCEDURE
COMPARISON OF BGBP VS STD GBP
Outcome after the operations BGBP STD GBP
Av Initial weight loss 1-3yrs gt77 65-70
Weight loss 4-10 years 70-77 55-65
Resolution of T2DM 80--85 60-80
VomitingSolid Food Intolerance 5-15 lt5
Significant Weight regain 3-7 10-35
Ringband Erosion 0-2 NA
CHOICE OF PROCEDURE
OAGBPMGB
One Anastamosis Gastric BypassMini Gastric Bypass (OAGBMGB)
Simplicity
Repeatability
Minimal Dissection
Reversibility
Exit Strategy
Safety
Minimal Suturing
Short Duration
Short Learning Curve
CHOICE OF PROCEDURE
OAGBSAGBMGB Advantagesbull Easier operation compared to Standard GBPbull Better food tolerancebull More weight loss than standard GBPbull Better weigh Loss Maintenancebull Higher metabolic effect on T2DM and Hyperlipidemiabull Less incidence of internal herniabull More options for revision if needed
Disadvantagesbull Bile reflux gastritis and esophagitisbull Marginal ulcersbull Nutrient deficienciesbull Protein Caloric Malnutrition
Quan Y Huanh A Ye M Efficacy of laproscopic mini gastric bypass for obesity and type 2 diabetes mellitus A systematic review and met-analysis Gastroenterol Res Pract 2015 ID 152852 10155
CHOICE OF PROCEDURE
2015 ndash Review articleVictorzon M et al Scand J Surg 2015 Mar104(1)48-53 Single-anastomosis gastric
bypass better faster and safer
bull The abstracts of 73 articles were reviewed and after removal of case studies duplicates and irrelevant articles 10 articles remained for closer review
bull Several thousand of this operation have been performed for more than 15 years It is claimed to be an easier safer faster and more effective metabolic operation compared to the standard Roux-en-Y gastric bypass The proponents of this operation also claim that this operation is easier to revise and reverse leaving more options compared to the situation after standard bypass in case of failure However there is much controversy surrounding this method mainly concerning the possible harmful and in the long-term even carcinogenic effects of biliopancreaticoduodenal reflux in the gastric pouch
Comment
Several thousands MGBs performed over 15 yrsEasier safer faster amp more effective than
RYGBEasier to revise amp reverse
Controversy regarding carcinogenic effect of BPD reflux
1306
1213
1294
1218
131
1207
114
116
118
12
122
124
126
128
13
132
Before After
BGB LGB MGB
Hemoglobin
RYGB VS Banded RYGB VS OAGBMGB
CHOICE OF PROCEDURE
399
372
394
36
396
352
32
33
34
35
36
37
38
39
4
41
Before After
BGB LGB MGB
Albumin661
644
693
67
685
607
56
58
6
62
64
66
68
7
Before After
BGB LGB MGB
Protein
RYGB VS Banded RYGB VS OAGBMGB
CHOICE OF PROCEDURE
911
87
906
873
909
833
78
8
82
84
86
88
9
92
Before After
BGB LGB MGB
Calcium
CHOICE OF PROCEDURE
RYGB VS Banded RYGB VS OAGBMGB
COMPARISON OF BGBP OAGB VS STD GBP
Outcome after the operations BGBP OAGBP STD GBP
Av Initial weight loss 1-3yrs gt77 gt77 65-70
Weight loss 4-10 years 70-77 70-77 55-65
Resolution of T2DM 80--85 80-90 60-80
VomitingSolid Food Intolerance 5-15 lt5 lt5
Diarrhea and Steatorrhea 1-2A 15-30 NA
Symptomatic Reflux 1-3 3-11 1-3
Marginal Ulcers 3-5 3-5 3-5
Protein Caloric Malnutrition lt1 3-11 lt1
Significant Weight regain 3-10 3-10 10-35
Ringband Erosion 0-1 NA NA
CHOICE OF PROCEDURE
We have enough information currently to enhance the outcome and minimize the risk by matching the operation to the patient
That is the basis forAn Algorithm for Bariatric Metabolic Operations
CHOOSING THE BEST BARIATRIC METABOLIC PROCEDURE FOR THE PATIENT
CHOICE OF PROCEDURE
bull All agesbull With no diabetesbull With low BMI preferably lt40bull With no GERDbull With HO PUDbull With HO or findings of liver diseasebull With Inflammatory bowel diseasebull With dense adhesions from multiple small bowel surgeriesbull Without HO VTEbull In heavy smokers who are not likely to quitbull In gastric cancer endemic areasbull High Risk needing minimal anesthesia and OR timebull High BMI gt 60 as part of a two stage approach
ALGORITHM
LSG BSG
CHOICE OF PROCEDURE
Laparoscopic Sleeve Gastrectomy Or Banded Sleeve Gastrostomy (SGBSD) Indicated for Patients
-All ages-Patients with T2DM lt5years and HbA1-c lt8 C-Peptidegt2 and not on insulin
-Patients with GERD
-ALL BMI ----- -BGBPBMIlt50-- LGBP
Vegetarian (BGBP)
BGBPLGBP
CHOICE OF PROCEDURE
ALGORITHM
Laparoscopic Gastric Bypass(LGBP) or Banded Gastric Bypass(BGBP) Indicated for Patients
bull With Diabetes gt5 years HbA1cgt8 C-Peptide lt2andor on Insulinbull All agesbull All BMI particularly High BMI-gt50bull High risk patients with need for short anesthesia timebull Because it is an easy to perform procedurebull Best tolerated by non Vegetarian
bull GERD Is a contraindicationbull Liver disease is a contraindication
Must be able to follow up patient regularlyPatient must be able to afford the required supplements OAGB
CHOICE OF PROCEDURE
ALGORITHM
OAGBMGB for patients
Sleeve gastrectomy with duodenal bypass(SGDJB) in patients with indication for Gastric Bypass in Gastric Cancer Endemic Areas
As effective as GBPSame weight loss andmetabolic effects as gastric bypass
SG-DJB
CHOICE OF PROCEDURE
ALGORITHM
Sleeve gastrectomy with duodenal bypass(SGDJB) in patients
1Second stage operation for the sleeve gastrectomy
2 Non responders or complications of sleeve gastric bypass or OAGBMGB
BPD-DS SADI SASI SG with enteral bypass
CHOICE OF PROCEDURE
ALGORITHM
BPD-DS SADI SAGI SASI) Indicated for
Areas with high incidence of anemia and very strict vegetarian food habits
CHOICE OF PROCEDURE
ALGORITHM
Sleeve Gastrectomy with gastro-jejunal gastro-ileal or entero-enteral anastomosis
Intra Gastric Balloon ENDOBARRIER
V-BLOC Aspire AssistEndoscopic Plication
For a patient who does not want an intra abdominal gastro-intestinal procedure
CHOICE OF PROCEDURE
Should You Do A Bariatric Metabolic Operation Because That Is What The Patient Wantsrdquo
NOYESmdashIt depends HoweverA bariatric metabolic surgeon should be able to offer the best operation for the patient based on the patientrsquos profile It is good practice to refer the patient to a tertiary center if the surgeon does not offer the operation that meets the patients indication
CHOICE OF PROCEDURE
CHOOSING THE BEST BARIATRIC METABOLIC PROCEDURE FOR THE PATIENT
CHOICE OF PROCEDURE
Case 157 yo Male BMI 57KgM2 T2DM GERD Strict Vegetarian
Algorithm
Gastric bypass-----Preferably Banded gastric bypassmdash------GERD Vegetarian
Not Sleeve because of T2DM GERD and High BMI
Not OAGBMGB because of GERD and probable of protein deficiency
CHOOSING THE BEST BARIATRIC METABOLIC PROCEDURE FOR THE PATIENT
CHOICE OF PROCEDURE
Case 1128 y0 F BMI 42 PCO DUB OSA and HO Migraine headaches
AlgorithmSleeve GastrectomymdashPreferably a Ring banded Sleeve gastrectomy
----No T2DM---No GERDNot Gastric bypass mdash anemia smelly flatus
Not OAGBMGB----Anemia Foul smelling flatus and body odor----Protein deficiency
CHOOSING THE BEST BARIATRIC METABOLIC PROCEDURE FOR THE PATIENT
CHOICE OF PROCEDURE
Case 11137 yo Male BMI 68 OSA OA and a non vegetarian who works at your hospitalReferred by the pulmonologist at your medical Centre
Algorithm
OAGBMGBmdashHigh BMI Non Veg-better food tolerance patient very likely to be followedand to afford the supplements because of proximity to your center
Not sleeve---poor weight loss with sleeve in super obeseNot Banded sleeve---Good weight loss but poor food tolerance since patient is a non vegetarianNot Gastric bypass---Weight loss in super obese have high non response after gastric bypass
and the gastric bypass is technically a more difficult operation than the OAGBNot Banded gastric bypass ndashGood weight loss but a BGBP is a more difficult operation and
the patient will have some food intolerance because of the ring
SURGICAL TREATMENT OPTIONS
At Mohak we perform these standard three operations and their banded modifications
Sleeve Gastrectomy Gastric Bypass OAGBMGB
CHOICE OF PROCEDURE
Evidence based operations performed at MBRSC From 2010 t0 2017---Standardized OperationsLaparoscopic Sleeve Gastrectomybull 90-120 cc Sleevebull 2-5cm from pylorusbull Where a sleeve is indicated but a band is contraindicated or not affordableBanded Sleeve Gastrectomy (BSG) 84 EWL after 60 monthsbull 90-120 cc Sleevebull 2-5cm from pylorusbull Ring 65-75 cmbull At 3-6 cm below GE junctionBanded Gastric bypass (BGBP) 75 EWL 48 monthsbull Create 6mdash7cm long pouchbull 65-75 cm ring at 3-5 cm below GE junction and gt2cm above anastomosisbull Large Gastroenterostomy gt 2cm bull 100cm Roux Limb and 80 cm BP limb for BMIlt50bull 100cm Roux Limb and 150 cm BP limb for BMIgt50Mini-Gastric Bypass (MGB) (OAGB) 79 EWL 60 monthsbull 9-18cm long pouch ~25cm widebull BP Limb length of 180cm BMIlt50Banded Mini-Gastric Bypass(BMGB)(BOAGB)bull 9-18cm long pouch ~25cm widebull Ring 7-75 cmbull BP Limb length of 180cm BMI50
THE MOHAK PROTOCOLStandardized Bariatric and Robotic Surgery Operations
CHOICE OF PROCEDURE
Sleeve Gastrectomy (LSG) or Banded Sleeve Gastrectomy (BSG)bull Non-diabeticsbull No hiatal hernia or GERDbull HO Smokingbull HO alcohol usebull HO PUDbull Abnormal LFTs NASH and early Cirrhosisbull Pts from areas with high incidence of gastric cancer of H pylori infectionbull High risks patients and super obese patients as part of a two-staged operation
Gastric Bypass (LGBP) or Banded Gastric Bypass (BGBP) or Hybrid BGBPMGBbull Have T2DM with HgbA1c lt 8 and duration lt 5 yearsbull Have Hiatal hernia or GERDbull Are Vegetarianbull No nicotine addiction (smoking)bull Have HO Alcohol intake bull Have NASH at surgery-No cirrhosisbull Not likely to come back for follow up andbull Revision operation of Failed Sleeve gastrectomy GBP or MGB
MOHAK ALGORITHM
CHOICE OF PROCEDURE
One Anastomosis Gastric Bypass-Mini-Gastric Bypass (OAGBP-MGB) bull Have T2DM with HgbA1c 8 and durationgt5 yearsbull Have No GERDbull Are Non-vegetarianbull Have poor dentitionbull Most likely to return for follow up at the clinicbull No HO alcohol intakebull No Nicotine addiction (smoking)bull Normal LFTsbull No NASH at surgery or cirrhosisbull Commitment by our program to have 100 follow up of theses patient
Revision Operationbull Sleeve to Banded RY with 100 cm Al limb and 180 cm BP Limbbull MGB to diverted MGB for Reflux Existing BPL and 100cm ALbull MGB to GBP for PCM or reversal to normal anatomy for PCMmdashinterim gastrostomy feedingbull GBP to BGBP with 180cm BP limb for Weight regain or inadequate weight loss BMIlt40bull GBP to BGBP with 300cm common limb for Weight regain or inadequate weight loss BMIgt40
MOHAK ALGORITHM
CHOICE OF PROCEDURE
bull Laparoscopic Gastric Bypass
bull Laparoscopic Sleeve Gastrectomy
bull Divided Mini-Gastric Bypass
bull Biliopancreatic Diversion with DS
bull Single Anastomosis Duodeno-ileostomy
bull Gastric Plication
bull Banded Gastric Plication
bull Endoscopic Gastroplasty
bull Laparoscopic Adjustable Gastric bands
bull Balloon Implantation
bull Ileal interposition
These other operations will be used selectively based on patients needs and the surgeons determination
CHOICE OF PROCEDURE
The MOHAK Guide for Choice of Bariatric Metabolic Surgery Operations
Single Incision Laparoscopic Robotic and Endoscopic approaches are
available at patientsrsquo requests and the discretion of the surgeon
CHOICE OF PROCEDURE
The MOHAK Guide for Choice of Bariatric Metabolic Surgery Operations
Mohak Bariatrics and Robotics Surgery Center Motto
ldquoThe best operation for the patient by a competent surgeon in a well equipped hospital to maximize outcomes with the least amount of risks exposurerdquo
WE ARE ABLE TO CHOOSE THE BEST BARIATRIC METABOLIC PROCEDURE FOR YOUR PATIENT
Good long-term results are our marketing toolSuccessful patients make a lot of referralsbull
CHOICE OF PROCEDURE
The MOHAK Guide for Choice of Bariatric Metabolic Surgery Operations
We offer various treatment modalities for obesity The operation is
determined by the profile of the patient and guided by findings from
analysis of the data from our prospectively maintained database
MOHAK TEAM INDORE INDIA
THANK YOU
CHOICE OF PROCEDURE
Sleeve Gastrectomy Ring BandedSleeve Gastrectomy
The Ring Stabilizes The Size of The Sleeveand minimizes the disadvantagesSEEVE GASTRECTOMY
1 Relatively simple operation2 No disruption of gastrointestinal tract3 No gastro-intestinal anastomosis4 Nearly regular intestinal absorption 5 Low incidence of dumping syndrome6 0 risk of developing an internal hernia 7 Good weight loss and resolution of
co-morbid conditions almost equal to GBP
Disadvantages-Weight loss ltLGBP-Dilation of sleeve with weight regain and recurrence of co-morbid conditions
-Neo-reflux-Intractable leaks-Torsionstenosis-Porto-mesenteric thrombosis
CHOICE OF PROCEDURE
Sleeve Gastrectomy
Ring BandedSleeve Gastrectomy
06M 1 yr 2yr 3yr 4yr 5yr 6yr
EB
WL
Follow UP
p vs Baseline always lt0001 BSG LSG
Bhandari M Mathur W etal In Print SOARD
CHOICE OF PROCEDURE
THREE YEARS SIX YEARS
THREE YEARS SIX YEARSLess than 50 50-75 above75 Less than 50 50-75 above75
BSG (0) 0 (2) 35 (56) 965 (0) 0 (4) 83 (44) 917
LSG (15)111 (66)474 (53)395 (46)469 (46)469 (9)91
0102030405060708090
100
BSG
LSG
3 YEARSLSG 111BSG 0
FAILURE RATE
6 YEARSLSG 469BSG 0
CHOICE OF PROCEDURE
CHOICE OF PROCEDURE
Bhandari M Mathur W Mishra A MBRSC Course May 2017 Indore India
The Gastric Bypass is the Gold Standard of Bariatric Metabolic Operations
RGBP BGBP
CHOICE OF PROCEDURE
COMPARISON OF BGBP VS STD GBP
Outcome after the operations BGBP STD GBP
Av Initial weight loss 1-3yrs gt77 65-70
Weight loss 4-10 years 70-77 55-65
Resolution of T2DM 80--85 60-80
VomitingSolid Food Intolerance 5-15 lt5
Significant Weight regain 3-7 10-35
Ringband Erosion 0-2 NA
CHOICE OF PROCEDURE
OAGBPMGB
One Anastamosis Gastric BypassMini Gastric Bypass (OAGBMGB)
Simplicity
Repeatability
Minimal Dissection
Reversibility
Exit Strategy
Safety
Minimal Suturing
Short Duration
Short Learning Curve
CHOICE OF PROCEDURE
OAGBSAGBMGB Advantagesbull Easier operation compared to Standard GBPbull Better food tolerancebull More weight loss than standard GBPbull Better weigh Loss Maintenancebull Higher metabolic effect on T2DM and Hyperlipidemiabull Less incidence of internal herniabull More options for revision if needed
Disadvantagesbull Bile reflux gastritis and esophagitisbull Marginal ulcersbull Nutrient deficienciesbull Protein Caloric Malnutrition
Quan Y Huanh A Ye M Efficacy of laproscopic mini gastric bypass for obesity and type 2 diabetes mellitus A systematic review and met-analysis Gastroenterol Res Pract 2015 ID 152852 10155
CHOICE OF PROCEDURE
2015 ndash Review articleVictorzon M et al Scand J Surg 2015 Mar104(1)48-53 Single-anastomosis gastric
bypass better faster and safer
bull The abstracts of 73 articles were reviewed and after removal of case studies duplicates and irrelevant articles 10 articles remained for closer review
bull Several thousand of this operation have been performed for more than 15 years It is claimed to be an easier safer faster and more effective metabolic operation compared to the standard Roux-en-Y gastric bypass The proponents of this operation also claim that this operation is easier to revise and reverse leaving more options compared to the situation after standard bypass in case of failure However there is much controversy surrounding this method mainly concerning the possible harmful and in the long-term even carcinogenic effects of biliopancreaticoduodenal reflux in the gastric pouch
Comment
Several thousands MGBs performed over 15 yrsEasier safer faster amp more effective than
RYGBEasier to revise amp reverse
Controversy regarding carcinogenic effect of BPD reflux
1306
1213
1294
1218
131
1207
114
116
118
12
122
124
126
128
13
132
Before After
BGB LGB MGB
Hemoglobin
RYGB VS Banded RYGB VS OAGBMGB
CHOICE OF PROCEDURE
399
372
394
36
396
352
32
33
34
35
36
37
38
39
4
41
Before After
BGB LGB MGB
Albumin661
644
693
67
685
607
56
58
6
62
64
66
68
7
Before After
BGB LGB MGB
Protein
RYGB VS Banded RYGB VS OAGBMGB
CHOICE OF PROCEDURE
911
87
906
873
909
833
78
8
82
84
86
88
9
92
Before After
BGB LGB MGB
Calcium
CHOICE OF PROCEDURE
RYGB VS Banded RYGB VS OAGBMGB
COMPARISON OF BGBP OAGB VS STD GBP
Outcome after the operations BGBP OAGBP STD GBP
Av Initial weight loss 1-3yrs gt77 gt77 65-70
Weight loss 4-10 years 70-77 70-77 55-65
Resolution of T2DM 80--85 80-90 60-80
VomitingSolid Food Intolerance 5-15 lt5 lt5
Diarrhea and Steatorrhea 1-2A 15-30 NA
Symptomatic Reflux 1-3 3-11 1-3
Marginal Ulcers 3-5 3-5 3-5
Protein Caloric Malnutrition lt1 3-11 lt1
Significant Weight regain 3-10 3-10 10-35
Ringband Erosion 0-1 NA NA
CHOICE OF PROCEDURE
We have enough information currently to enhance the outcome and minimize the risk by matching the operation to the patient
That is the basis forAn Algorithm for Bariatric Metabolic Operations
CHOOSING THE BEST BARIATRIC METABOLIC PROCEDURE FOR THE PATIENT
CHOICE OF PROCEDURE
bull All agesbull With no diabetesbull With low BMI preferably lt40bull With no GERDbull With HO PUDbull With HO or findings of liver diseasebull With Inflammatory bowel diseasebull With dense adhesions from multiple small bowel surgeriesbull Without HO VTEbull In heavy smokers who are not likely to quitbull In gastric cancer endemic areasbull High Risk needing minimal anesthesia and OR timebull High BMI gt 60 as part of a two stage approach
ALGORITHM
LSG BSG
CHOICE OF PROCEDURE
Laparoscopic Sleeve Gastrectomy Or Banded Sleeve Gastrostomy (SGBSD) Indicated for Patients
-All ages-Patients with T2DM lt5years and HbA1-c lt8 C-Peptidegt2 and not on insulin
-Patients with GERD
-ALL BMI ----- -BGBPBMIlt50-- LGBP
Vegetarian (BGBP)
BGBPLGBP
CHOICE OF PROCEDURE
ALGORITHM
Laparoscopic Gastric Bypass(LGBP) or Banded Gastric Bypass(BGBP) Indicated for Patients
bull With Diabetes gt5 years HbA1cgt8 C-Peptide lt2andor on Insulinbull All agesbull All BMI particularly High BMI-gt50bull High risk patients with need for short anesthesia timebull Because it is an easy to perform procedurebull Best tolerated by non Vegetarian
bull GERD Is a contraindicationbull Liver disease is a contraindication
Must be able to follow up patient regularlyPatient must be able to afford the required supplements OAGB
CHOICE OF PROCEDURE
ALGORITHM
OAGBMGB for patients
Sleeve gastrectomy with duodenal bypass(SGDJB) in patients with indication for Gastric Bypass in Gastric Cancer Endemic Areas
As effective as GBPSame weight loss andmetabolic effects as gastric bypass
SG-DJB
CHOICE OF PROCEDURE
ALGORITHM
Sleeve gastrectomy with duodenal bypass(SGDJB) in patients
1Second stage operation for the sleeve gastrectomy
2 Non responders or complications of sleeve gastric bypass or OAGBMGB
BPD-DS SADI SASI SG with enteral bypass
CHOICE OF PROCEDURE
ALGORITHM
BPD-DS SADI SAGI SASI) Indicated for
Areas with high incidence of anemia and very strict vegetarian food habits
CHOICE OF PROCEDURE
ALGORITHM
Sleeve Gastrectomy with gastro-jejunal gastro-ileal or entero-enteral anastomosis
Intra Gastric Balloon ENDOBARRIER
V-BLOC Aspire AssistEndoscopic Plication
For a patient who does not want an intra abdominal gastro-intestinal procedure
CHOICE OF PROCEDURE
Should You Do A Bariatric Metabolic Operation Because That Is What The Patient Wantsrdquo
NOYESmdashIt depends HoweverA bariatric metabolic surgeon should be able to offer the best operation for the patient based on the patientrsquos profile It is good practice to refer the patient to a tertiary center if the surgeon does not offer the operation that meets the patients indication
CHOICE OF PROCEDURE
CHOOSING THE BEST BARIATRIC METABOLIC PROCEDURE FOR THE PATIENT
CHOICE OF PROCEDURE
Case 157 yo Male BMI 57KgM2 T2DM GERD Strict Vegetarian
Algorithm
Gastric bypass-----Preferably Banded gastric bypassmdash------GERD Vegetarian
Not Sleeve because of T2DM GERD and High BMI
Not OAGBMGB because of GERD and probable of protein deficiency
CHOOSING THE BEST BARIATRIC METABOLIC PROCEDURE FOR THE PATIENT
CHOICE OF PROCEDURE
Case 1128 y0 F BMI 42 PCO DUB OSA and HO Migraine headaches
AlgorithmSleeve GastrectomymdashPreferably a Ring banded Sleeve gastrectomy
----No T2DM---No GERDNot Gastric bypass mdash anemia smelly flatus
Not OAGBMGB----Anemia Foul smelling flatus and body odor----Protein deficiency
CHOOSING THE BEST BARIATRIC METABOLIC PROCEDURE FOR THE PATIENT
CHOICE OF PROCEDURE
Case 11137 yo Male BMI 68 OSA OA and a non vegetarian who works at your hospitalReferred by the pulmonologist at your medical Centre
Algorithm
OAGBMGBmdashHigh BMI Non Veg-better food tolerance patient very likely to be followedand to afford the supplements because of proximity to your center
Not sleeve---poor weight loss with sleeve in super obeseNot Banded sleeve---Good weight loss but poor food tolerance since patient is a non vegetarianNot Gastric bypass---Weight loss in super obese have high non response after gastric bypass
and the gastric bypass is technically a more difficult operation than the OAGBNot Banded gastric bypass ndashGood weight loss but a BGBP is a more difficult operation and
the patient will have some food intolerance because of the ring
SURGICAL TREATMENT OPTIONS
At Mohak we perform these standard three operations and their banded modifications
Sleeve Gastrectomy Gastric Bypass OAGBMGB
CHOICE OF PROCEDURE
Evidence based operations performed at MBRSC From 2010 t0 2017---Standardized OperationsLaparoscopic Sleeve Gastrectomybull 90-120 cc Sleevebull 2-5cm from pylorusbull Where a sleeve is indicated but a band is contraindicated or not affordableBanded Sleeve Gastrectomy (BSG) 84 EWL after 60 monthsbull 90-120 cc Sleevebull 2-5cm from pylorusbull Ring 65-75 cmbull At 3-6 cm below GE junctionBanded Gastric bypass (BGBP) 75 EWL 48 monthsbull Create 6mdash7cm long pouchbull 65-75 cm ring at 3-5 cm below GE junction and gt2cm above anastomosisbull Large Gastroenterostomy gt 2cm bull 100cm Roux Limb and 80 cm BP limb for BMIlt50bull 100cm Roux Limb and 150 cm BP limb for BMIgt50Mini-Gastric Bypass (MGB) (OAGB) 79 EWL 60 monthsbull 9-18cm long pouch ~25cm widebull BP Limb length of 180cm BMIlt50Banded Mini-Gastric Bypass(BMGB)(BOAGB)bull 9-18cm long pouch ~25cm widebull Ring 7-75 cmbull BP Limb length of 180cm BMI50
THE MOHAK PROTOCOLStandardized Bariatric and Robotic Surgery Operations
CHOICE OF PROCEDURE
Sleeve Gastrectomy (LSG) or Banded Sleeve Gastrectomy (BSG)bull Non-diabeticsbull No hiatal hernia or GERDbull HO Smokingbull HO alcohol usebull HO PUDbull Abnormal LFTs NASH and early Cirrhosisbull Pts from areas with high incidence of gastric cancer of H pylori infectionbull High risks patients and super obese patients as part of a two-staged operation
Gastric Bypass (LGBP) or Banded Gastric Bypass (BGBP) or Hybrid BGBPMGBbull Have T2DM with HgbA1c lt 8 and duration lt 5 yearsbull Have Hiatal hernia or GERDbull Are Vegetarianbull No nicotine addiction (smoking)bull Have HO Alcohol intake bull Have NASH at surgery-No cirrhosisbull Not likely to come back for follow up andbull Revision operation of Failed Sleeve gastrectomy GBP or MGB
MOHAK ALGORITHM
CHOICE OF PROCEDURE
One Anastomosis Gastric Bypass-Mini-Gastric Bypass (OAGBP-MGB) bull Have T2DM with HgbA1c 8 and durationgt5 yearsbull Have No GERDbull Are Non-vegetarianbull Have poor dentitionbull Most likely to return for follow up at the clinicbull No HO alcohol intakebull No Nicotine addiction (smoking)bull Normal LFTsbull No NASH at surgery or cirrhosisbull Commitment by our program to have 100 follow up of theses patient
Revision Operationbull Sleeve to Banded RY with 100 cm Al limb and 180 cm BP Limbbull MGB to diverted MGB for Reflux Existing BPL and 100cm ALbull MGB to GBP for PCM or reversal to normal anatomy for PCMmdashinterim gastrostomy feedingbull GBP to BGBP with 180cm BP limb for Weight regain or inadequate weight loss BMIlt40bull GBP to BGBP with 300cm common limb for Weight regain or inadequate weight loss BMIgt40
MOHAK ALGORITHM
CHOICE OF PROCEDURE
bull Laparoscopic Gastric Bypass
bull Laparoscopic Sleeve Gastrectomy
bull Divided Mini-Gastric Bypass
bull Biliopancreatic Diversion with DS
bull Single Anastomosis Duodeno-ileostomy
bull Gastric Plication
bull Banded Gastric Plication
bull Endoscopic Gastroplasty
bull Laparoscopic Adjustable Gastric bands
bull Balloon Implantation
bull Ileal interposition
These other operations will be used selectively based on patients needs and the surgeons determination
CHOICE OF PROCEDURE
The MOHAK Guide for Choice of Bariatric Metabolic Surgery Operations
Single Incision Laparoscopic Robotic and Endoscopic approaches are
available at patientsrsquo requests and the discretion of the surgeon
CHOICE OF PROCEDURE
The MOHAK Guide for Choice of Bariatric Metabolic Surgery Operations
Mohak Bariatrics and Robotics Surgery Center Motto
ldquoThe best operation for the patient by a competent surgeon in a well equipped hospital to maximize outcomes with the least amount of risks exposurerdquo
WE ARE ABLE TO CHOOSE THE BEST BARIATRIC METABOLIC PROCEDURE FOR YOUR PATIENT
Good long-term results are our marketing toolSuccessful patients make a lot of referralsbull
CHOICE OF PROCEDURE
The MOHAK Guide for Choice of Bariatric Metabolic Surgery Operations
We offer various treatment modalities for obesity The operation is
determined by the profile of the patient and guided by findings from
analysis of the data from our prospectively maintained database
MOHAK TEAM INDORE INDIA
THANK YOU
Sleeve Gastrectomy Ring BandedSleeve Gastrectomy
The Ring Stabilizes The Size of The Sleeveand minimizes the disadvantagesSEEVE GASTRECTOMY
1 Relatively simple operation2 No disruption of gastrointestinal tract3 No gastro-intestinal anastomosis4 Nearly regular intestinal absorption 5 Low incidence of dumping syndrome6 0 risk of developing an internal hernia 7 Good weight loss and resolution of
co-morbid conditions almost equal to GBP
Disadvantages-Weight loss ltLGBP-Dilation of sleeve with weight regain and recurrence of co-morbid conditions
-Neo-reflux-Intractable leaks-Torsionstenosis-Porto-mesenteric thrombosis
CHOICE OF PROCEDURE
Sleeve Gastrectomy
Ring BandedSleeve Gastrectomy
06M 1 yr 2yr 3yr 4yr 5yr 6yr
EB
WL
Follow UP
p vs Baseline always lt0001 BSG LSG
Bhandari M Mathur W etal In Print SOARD
CHOICE OF PROCEDURE
THREE YEARS SIX YEARS
THREE YEARS SIX YEARSLess than 50 50-75 above75 Less than 50 50-75 above75
BSG (0) 0 (2) 35 (56) 965 (0) 0 (4) 83 (44) 917
LSG (15)111 (66)474 (53)395 (46)469 (46)469 (9)91
0102030405060708090
100
BSG
LSG
3 YEARSLSG 111BSG 0
FAILURE RATE
6 YEARSLSG 469BSG 0
CHOICE OF PROCEDURE
CHOICE OF PROCEDURE
Bhandari M Mathur W Mishra A MBRSC Course May 2017 Indore India
The Gastric Bypass is the Gold Standard of Bariatric Metabolic Operations
RGBP BGBP
CHOICE OF PROCEDURE
COMPARISON OF BGBP VS STD GBP
Outcome after the operations BGBP STD GBP
Av Initial weight loss 1-3yrs gt77 65-70
Weight loss 4-10 years 70-77 55-65
Resolution of T2DM 80--85 60-80
VomitingSolid Food Intolerance 5-15 lt5
Significant Weight regain 3-7 10-35
Ringband Erosion 0-2 NA
CHOICE OF PROCEDURE
OAGBPMGB
One Anastamosis Gastric BypassMini Gastric Bypass (OAGBMGB)
Simplicity
Repeatability
Minimal Dissection
Reversibility
Exit Strategy
Safety
Minimal Suturing
Short Duration
Short Learning Curve
CHOICE OF PROCEDURE
OAGBSAGBMGB Advantagesbull Easier operation compared to Standard GBPbull Better food tolerancebull More weight loss than standard GBPbull Better weigh Loss Maintenancebull Higher metabolic effect on T2DM and Hyperlipidemiabull Less incidence of internal herniabull More options for revision if needed
Disadvantagesbull Bile reflux gastritis and esophagitisbull Marginal ulcersbull Nutrient deficienciesbull Protein Caloric Malnutrition
Quan Y Huanh A Ye M Efficacy of laproscopic mini gastric bypass for obesity and type 2 diabetes mellitus A systematic review and met-analysis Gastroenterol Res Pract 2015 ID 152852 10155
CHOICE OF PROCEDURE
2015 ndash Review articleVictorzon M et al Scand J Surg 2015 Mar104(1)48-53 Single-anastomosis gastric
bypass better faster and safer
bull The abstracts of 73 articles were reviewed and after removal of case studies duplicates and irrelevant articles 10 articles remained for closer review
bull Several thousand of this operation have been performed for more than 15 years It is claimed to be an easier safer faster and more effective metabolic operation compared to the standard Roux-en-Y gastric bypass The proponents of this operation also claim that this operation is easier to revise and reverse leaving more options compared to the situation after standard bypass in case of failure However there is much controversy surrounding this method mainly concerning the possible harmful and in the long-term even carcinogenic effects of biliopancreaticoduodenal reflux in the gastric pouch
Comment
Several thousands MGBs performed over 15 yrsEasier safer faster amp more effective than
RYGBEasier to revise amp reverse
Controversy regarding carcinogenic effect of BPD reflux
1306
1213
1294
1218
131
1207
114
116
118
12
122
124
126
128
13
132
Before After
BGB LGB MGB
Hemoglobin
RYGB VS Banded RYGB VS OAGBMGB
CHOICE OF PROCEDURE
399
372
394
36
396
352
32
33
34
35
36
37
38
39
4
41
Before After
BGB LGB MGB
Albumin661
644
693
67
685
607
56
58
6
62
64
66
68
7
Before After
BGB LGB MGB
Protein
RYGB VS Banded RYGB VS OAGBMGB
CHOICE OF PROCEDURE
911
87
906
873
909
833
78
8
82
84
86
88
9
92
Before After
BGB LGB MGB
Calcium
CHOICE OF PROCEDURE
RYGB VS Banded RYGB VS OAGBMGB
COMPARISON OF BGBP OAGB VS STD GBP
Outcome after the operations BGBP OAGBP STD GBP
Av Initial weight loss 1-3yrs gt77 gt77 65-70
Weight loss 4-10 years 70-77 70-77 55-65
Resolution of T2DM 80--85 80-90 60-80
VomitingSolid Food Intolerance 5-15 lt5 lt5
Diarrhea and Steatorrhea 1-2A 15-30 NA
Symptomatic Reflux 1-3 3-11 1-3
Marginal Ulcers 3-5 3-5 3-5
Protein Caloric Malnutrition lt1 3-11 lt1
Significant Weight regain 3-10 3-10 10-35
Ringband Erosion 0-1 NA NA
CHOICE OF PROCEDURE
We have enough information currently to enhance the outcome and minimize the risk by matching the operation to the patient
That is the basis forAn Algorithm for Bariatric Metabolic Operations
CHOOSING THE BEST BARIATRIC METABOLIC PROCEDURE FOR THE PATIENT
CHOICE OF PROCEDURE
bull All agesbull With no diabetesbull With low BMI preferably lt40bull With no GERDbull With HO PUDbull With HO or findings of liver diseasebull With Inflammatory bowel diseasebull With dense adhesions from multiple small bowel surgeriesbull Without HO VTEbull In heavy smokers who are not likely to quitbull In gastric cancer endemic areasbull High Risk needing minimal anesthesia and OR timebull High BMI gt 60 as part of a two stage approach
ALGORITHM
LSG BSG
CHOICE OF PROCEDURE
Laparoscopic Sleeve Gastrectomy Or Banded Sleeve Gastrostomy (SGBSD) Indicated for Patients
-All ages-Patients with T2DM lt5years and HbA1-c lt8 C-Peptidegt2 and not on insulin
-Patients with GERD
-ALL BMI ----- -BGBPBMIlt50-- LGBP
Vegetarian (BGBP)
BGBPLGBP
CHOICE OF PROCEDURE
ALGORITHM
Laparoscopic Gastric Bypass(LGBP) or Banded Gastric Bypass(BGBP) Indicated for Patients
bull With Diabetes gt5 years HbA1cgt8 C-Peptide lt2andor on Insulinbull All agesbull All BMI particularly High BMI-gt50bull High risk patients with need for short anesthesia timebull Because it is an easy to perform procedurebull Best tolerated by non Vegetarian
bull GERD Is a contraindicationbull Liver disease is a contraindication
Must be able to follow up patient regularlyPatient must be able to afford the required supplements OAGB
CHOICE OF PROCEDURE
ALGORITHM
OAGBMGB for patients
Sleeve gastrectomy with duodenal bypass(SGDJB) in patients with indication for Gastric Bypass in Gastric Cancer Endemic Areas
As effective as GBPSame weight loss andmetabolic effects as gastric bypass
SG-DJB
CHOICE OF PROCEDURE
ALGORITHM
Sleeve gastrectomy with duodenal bypass(SGDJB) in patients
1Second stage operation for the sleeve gastrectomy
2 Non responders or complications of sleeve gastric bypass or OAGBMGB
BPD-DS SADI SASI SG with enteral bypass
CHOICE OF PROCEDURE
ALGORITHM
BPD-DS SADI SAGI SASI) Indicated for
Areas with high incidence of anemia and very strict vegetarian food habits
CHOICE OF PROCEDURE
ALGORITHM
Sleeve Gastrectomy with gastro-jejunal gastro-ileal or entero-enteral anastomosis
Intra Gastric Balloon ENDOBARRIER
V-BLOC Aspire AssistEndoscopic Plication
For a patient who does not want an intra abdominal gastro-intestinal procedure
CHOICE OF PROCEDURE
Should You Do A Bariatric Metabolic Operation Because That Is What The Patient Wantsrdquo
NOYESmdashIt depends HoweverA bariatric metabolic surgeon should be able to offer the best operation for the patient based on the patientrsquos profile It is good practice to refer the patient to a tertiary center if the surgeon does not offer the operation that meets the patients indication
CHOICE OF PROCEDURE
CHOOSING THE BEST BARIATRIC METABOLIC PROCEDURE FOR THE PATIENT
CHOICE OF PROCEDURE
Case 157 yo Male BMI 57KgM2 T2DM GERD Strict Vegetarian
Algorithm
Gastric bypass-----Preferably Banded gastric bypassmdash------GERD Vegetarian
Not Sleeve because of T2DM GERD and High BMI
Not OAGBMGB because of GERD and probable of protein deficiency
CHOOSING THE BEST BARIATRIC METABOLIC PROCEDURE FOR THE PATIENT
CHOICE OF PROCEDURE
Case 1128 y0 F BMI 42 PCO DUB OSA and HO Migraine headaches
AlgorithmSleeve GastrectomymdashPreferably a Ring banded Sleeve gastrectomy
----No T2DM---No GERDNot Gastric bypass mdash anemia smelly flatus
Not OAGBMGB----Anemia Foul smelling flatus and body odor----Protein deficiency
CHOOSING THE BEST BARIATRIC METABOLIC PROCEDURE FOR THE PATIENT
CHOICE OF PROCEDURE
Case 11137 yo Male BMI 68 OSA OA and a non vegetarian who works at your hospitalReferred by the pulmonologist at your medical Centre
Algorithm
OAGBMGBmdashHigh BMI Non Veg-better food tolerance patient very likely to be followedand to afford the supplements because of proximity to your center
Not sleeve---poor weight loss with sleeve in super obeseNot Banded sleeve---Good weight loss but poor food tolerance since patient is a non vegetarianNot Gastric bypass---Weight loss in super obese have high non response after gastric bypass
and the gastric bypass is technically a more difficult operation than the OAGBNot Banded gastric bypass ndashGood weight loss but a BGBP is a more difficult operation and
the patient will have some food intolerance because of the ring
SURGICAL TREATMENT OPTIONS
At Mohak we perform these standard three operations and their banded modifications
Sleeve Gastrectomy Gastric Bypass OAGBMGB
CHOICE OF PROCEDURE
Evidence based operations performed at MBRSC From 2010 t0 2017---Standardized OperationsLaparoscopic Sleeve Gastrectomybull 90-120 cc Sleevebull 2-5cm from pylorusbull Where a sleeve is indicated but a band is contraindicated or not affordableBanded Sleeve Gastrectomy (BSG) 84 EWL after 60 monthsbull 90-120 cc Sleevebull 2-5cm from pylorusbull Ring 65-75 cmbull At 3-6 cm below GE junctionBanded Gastric bypass (BGBP) 75 EWL 48 monthsbull Create 6mdash7cm long pouchbull 65-75 cm ring at 3-5 cm below GE junction and gt2cm above anastomosisbull Large Gastroenterostomy gt 2cm bull 100cm Roux Limb and 80 cm BP limb for BMIlt50bull 100cm Roux Limb and 150 cm BP limb for BMIgt50Mini-Gastric Bypass (MGB) (OAGB) 79 EWL 60 monthsbull 9-18cm long pouch ~25cm widebull BP Limb length of 180cm BMIlt50Banded Mini-Gastric Bypass(BMGB)(BOAGB)bull 9-18cm long pouch ~25cm widebull Ring 7-75 cmbull BP Limb length of 180cm BMI50
THE MOHAK PROTOCOLStandardized Bariatric and Robotic Surgery Operations
CHOICE OF PROCEDURE
Sleeve Gastrectomy (LSG) or Banded Sleeve Gastrectomy (BSG)bull Non-diabeticsbull No hiatal hernia or GERDbull HO Smokingbull HO alcohol usebull HO PUDbull Abnormal LFTs NASH and early Cirrhosisbull Pts from areas with high incidence of gastric cancer of H pylori infectionbull High risks patients and super obese patients as part of a two-staged operation
Gastric Bypass (LGBP) or Banded Gastric Bypass (BGBP) or Hybrid BGBPMGBbull Have T2DM with HgbA1c lt 8 and duration lt 5 yearsbull Have Hiatal hernia or GERDbull Are Vegetarianbull No nicotine addiction (smoking)bull Have HO Alcohol intake bull Have NASH at surgery-No cirrhosisbull Not likely to come back for follow up andbull Revision operation of Failed Sleeve gastrectomy GBP or MGB
MOHAK ALGORITHM
CHOICE OF PROCEDURE
One Anastomosis Gastric Bypass-Mini-Gastric Bypass (OAGBP-MGB) bull Have T2DM with HgbA1c 8 and durationgt5 yearsbull Have No GERDbull Are Non-vegetarianbull Have poor dentitionbull Most likely to return for follow up at the clinicbull No HO alcohol intakebull No Nicotine addiction (smoking)bull Normal LFTsbull No NASH at surgery or cirrhosisbull Commitment by our program to have 100 follow up of theses patient
Revision Operationbull Sleeve to Banded RY with 100 cm Al limb and 180 cm BP Limbbull MGB to diverted MGB for Reflux Existing BPL and 100cm ALbull MGB to GBP for PCM or reversal to normal anatomy for PCMmdashinterim gastrostomy feedingbull GBP to BGBP with 180cm BP limb for Weight regain or inadequate weight loss BMIlt40bull GBP to BGBP with 300cm common limb for Weight regain or inadequate weight loss BMIgt40
MOHAK ALGORITHM
CHOICE OF PROCEDURE
bull Laparoscopic Gastric Bypass
bull Laparoscopic Sleeve Gastrectomy
bull Divided Mini-Gastric Bypass
bull Biliopancreatic Diversion with DS
bull Single Anastomosis Duodeno-ileostomy
bull Gastric Plication
bull Banded Gastric Plication
bull Endoscopic Gastroplasty
bull Laparoscopic Adjustable Gastric bands
bull Balloon Implantation
bull Ileal interposition
These other operations will be used selectively based on patients needs and the surgeons determination
CHOICE OF PROCEDURE
The MOHAK Guide for Choice of Bariatric Metabolic Surgery Operations
Single Incision Laparoscopic Robotic and Endoscopic approaches are
available at patientsrsquo requests and the discretion of the surgeon
CHOICE OF PROCEDURE
The MOHAK Guide for Choice of Bariatric Metabolic Surgery Operations
Mohak Bariatrics and Robotics Surgery Center Motto
ldquoThe best operation for the patient by a competent surgeon in a well equipped hospital to maximize outcomes with the least amount of risks exposurerdquo
WE ARE ABLE TO CHOOSE THE BEST BARIATRIC METABOLIC PROCEDURE FOR YOUR PATIENT
Good long-term results are our marketing toolSuccessful patients make a lot of referralsbull
CHOICE OF PROCEDURE
The MOHAK Guide for Choice of Bariatric Metabolic Surgery Operations
We offer various treatment modalities for obesity The operation is
determined by the profile of the patient and guided by findings from
analysis of the data from our prospectively maintained database
MOHAK TEAM INDORE INDIA
THANK YOU
Sleeve Gastrectomy
Ring BandedSleeve Gastrectomy
06M 1 yr 2yr 3yr 4yr 5yr 6yr
EB
WL
Follow UP
p vs Baseline always lt0001 BSG LSG
Bhandari M Mathur W etal In Print SOARD
CHOICE OF PROCEDURE
THREE YEARS SIX YEARS
THREE YEARS SIX YEARSLess than 50 50-75 above75 Less than 50 50-75 above75
BSG (0) 0 (2) 35 (56) 965 (0) 0 (4) 83 (44) 917
LSG (15)111 (66)474 (53)395 (46)469 (46)469 (9)91
0102030405060708090
100
BSG
LSG
3 YEARSLSG 111BSG 0
FAILURE RATE
6 YEARSLSG 469BSG 0
CHOICE OF PROCEDURE
CHOICE OF PROCEDURE
Bhandari M Mathur W Mishra A MBRSC Course May 2017 Indore India
The Gastric Bypass is the Gold Standard of Bariatric Metabolic Operations
RGBP BGBP
CHOICE OF PROCEDURE
COMPARISON OF BGBP VS STD GBP
Outcome after the operations BGBP STD GBP
Av Initial weight loss 1-3yrs gt77 65-70
Weight loss 4-10 years 70-77 55-65
Resolution of T2DM 80--85 60-80
VomitingSolid Food Intolerance 5-15 lt5
Significant Weight regain 3-7 10-35
Ringband Erosion 0-2 NA
CHOICE OF PROCEDURE
OAGBPMGB
One Anastamosis Gastric BypassMini Gastric Bypass (OAGBMGB)
Simplicity
Repeatability
Minimal Dissection
Reversibility
Exit Strategy
Safety
Minimal Suturing
Short Duration
Short Learning Curve
CHOICE OF PROCEDURE
OAGBSAGBMGB Advantagesbull Easier operation compared to Standard GBPbull Better food tolerancebull More weight loss than standard GBPbull Better weigh Loss Maintenancebull Higher metabolic effect on T2DM and Hyperlipidemiabull Less incidence of internal herniabull More options for revision if needed
Disadvantagesbull Bile reflux gastritis and esophagitisbull Marginal ulcersbull Nutrient deficienciesbull Protein Caloric Malnutrition
Quan Y Huanh A Ye M Efficacy of laproscopic mini gastric bypass for obesity and type 2 diabetes mellitus A systematic review and met-analysis Gastroenterol Res Pract 2015 ID 152852 10155
CHOICE OF PROCEDURE
2015 ndash Review articleVictorzon M et al Scand J Surg 2015 Mar104(1)48-53 Single-anastomosis gastric
bypass better faster and safer
bull The abstracts of 73 articles were reviewed and after removal of case studies duplicates and irrelevant articles 10 articles remained for closer review
bull Several thousand of this operation have been performed for more than 15 years It is claimed to be an easier safer faster and more effective metabolic operation compared to the standard Roux-en-Y gastric bypass The proponents of this operation also claim that this operation is easier to revise and reverse leaving more options compared to the situation after standard bypass in case of failure However there is much controversy surrounding this method mainly concerning the possible harmful and in the long-term even carcinogenic effects of biliopancreaticoduodenal reflux in the gastric pouch
Comment
Several thousands MGBs performed over 15 yrsEasier safer faster amp more effective than
RYGBEasier to revise amp reverse
Controversy regarding carcinogenic effect of BPD reflux
1306
1213
1294
1218
131
1207
114
116
118
12
122
124
126
128
13
132
Before After
BGB LGB MGB
Hemoglobin
RYGB VS Banded RYGB VS OAGBMGB
CHOICE OF PROCEDURE
399
372
394
36
396
352
32
33
34
35
36
37
38
39
4
41
Before After
BGB LGB MGB
Albumin661
644
693
67
685
607
56
58
6
62
64
66
68
7
Before After
BGB LGB MGB
Protein
RYGB VS Banded RYGB VS OAGBMGB
CHOICE OF PROCEDURE
911
87
906
873
909
833
78
8
82
84
86
88
9
92
Before After
BGB LGB MGB
Calcium
CHOICE OF PROCEDURE
RYGB VS Banded RYGB VS OAGBMGB
COMPARISON OF BGBP OAGB VS STD GBP
Outcome after the operations BGBP OAGBP STD GBP
Av Initial weight loss 1-3yrs gt77 gt77 65-70
Weight loss 4-10 years 70-77 70-77 55-65
Resolution of T2DM 80--85 80-90 60-80
VomitingSolid Food Intolerance 5-15 lt5 lt5
Diarrhea and Steatorrhea 1-2A 15-30 NA
Symptomatic Reflux 1-3 3-11 1-3
Marginal Ulcers 3-5 3-5 3-5
Protein Caloric Malnutrition lt1 3-11 lt1
Significant Weight regain 3-10 3-10 10-35
Ringband Erosion 0-1 NA NA
CHOICE OF PROCEDURE
We have enough information currently to enhance the outcome and minimize the risk by matching the operation to the patient
That is the basis forAn Algorithm for Bariatric Metabolic Operations
CHOOSING THE BEST BARIATRIC METABOLIC PROCEDURE FOR THE PATIENT
CHOICE OF PROCEDURE
bull All agesbull With no diabetesbull With low BMI preferably lt40bull With no GERDbull With HO PUDbull With HO or findings of liver diseasebull With Inflammatory bowel diseasebull With dense adhesions from multiple small bowel surgeriesbull Without HO VTEbull In heavy smokers who are not likely to quitbull In gastric cancer endemic areasbull High Risk needing minimal anesthesia and OR timebull High BMI gt 60 as part of a two stage approach
ALGORITHM
LSG BSG
CHOICE OF PROCEDURE
Laparoscopic Sleeve Gastrectomy Or Banded Sleeve Gastrostomy (SGBSD) Indicated for Patients
-All ages-Patients with T2DM lt5years and HbA1-c lt8 C-Peptidegt2 and not on insulin
-Patients with GERD
-ALL BMI ----- -BGBPBMIlt50-- LGBP
Vegetarian (BGBP)
BGBPLGBP
CHOICE OF PROCEDURE
ALGORITHM
Laparoscopic Gastric Bypass(LGBP) or Banded Gastric Bypass(BGBP) Indicated for Patients
bull With Diabetes gt5 years HbA1cgt8 C-Peptide lt2andor on Insulinbull All agesbull All BMI particularly High BMI-gt50bull High risk patients with need for short anesthesia timebull Because it is an easy to perform procedurebull Best tolerated by non Vegetarian
bull GERD Is a contraindicationbull Liver disease is a contraindication
Must be able to follow up patient regularlyPatient must be able to afford the required supplements OAGB
CHOICE OF PROCEDURE
ALGORITHM
OAGBMGB for patients
Sleeve gastrectomy with duodenal bypass(SGDJB) in patients with indication for Gastric Bypass in Gastric Cancer Endemic Areas
As effective as GBPSame weight loss andmetabolic effects as gastric bypass
SG-DJB
CHOICE OF PROCEDURE
ALGORITHM
Sleeve gastrectomy with duodenal bypass(SGDJB) in patients
1Second stage operation for the sleeve gastrectomy
2 Non responders or complications of sleeve gastric bypass or OAGBMGB
BPD-DS SADI SASI SG with enteral bypass
CHOICE OF PROCEDURE
ALGORITHM
BPD-DS SADI SAGI SASI) Indicated for
Areas with high incidence of anemia and very strict vegetarian food habits
CHOICE OF PROCEDURE
ALGORITHM
Sleeve Gastrectomy with gastro-jejunal gastro-ileal or entero-enteral anastomosis
Intra Gastric Balloon ENDOBARRIER
V-BLOC Aspire AssistEndoscopic Plication
For a patient who does not want an intra abdominal gastro-intestinal procedure
CHOICE OF PROCEDURE
Should You Do A Bariatric Metabolic Operation Because That Is What The Patient Wantsrdquo
NOYESmdashIt depends HoweverA bariatric metabolic surgeon should be able to offer the best operation for the patient based on the patientrsquos profile It is good practice to refer the patient to a tertiary center if the surgeon does not offer the operation that meets the patients indication
CHOICE OF PROCEDURE
CHOOSING THE BEST BARIATRIC METABOLIC PROCEDURE FOR THE PATIENT
CHOICE OF PROCEDURE
Case 157 yo Male BMI 57KgM2 T2DM GERD Strict Vegetarian
Algorithm
Gastric bypass-----Preferably Banded gastric bypassmdash------GERD Vegetarian
Not Sleeve because of T2DM GERD and High BMI
Not OAGBMGB because of GERD and probable of protein deficiency
CHOOSING THE BEST BARIATRIC METABOLIC PROCEDURE FOR THE PATIENT
CHOICE OF PROCEDURE
Case 1128 y0 F BMI 42 PCO DUB OSA and HO Migraine headaches
AlgorithmSleeve GastrectomymdashPreferably a Ring banded Sleeve gastrectomy
----No T2DM---No GERDNot Gastric bypass mdash anemia smelly flatus
Not OAGBMGB----Anemia Foul smelling flatus and body odor----Protein deficiency
CHOOSING THE BEST BARIATRIC METABOLIC PROCEDURE FOR THE PATIENT
CHOICE OF PROCEDURE
Case 11137 yo Male BMI 68 OSA OA and a non vegetarian who works at your hospitalReferred by the pulmonologist at your medical Centre
Algorithm
OAGBMGBmdashHigh BMI Non Veg-better food tolerance patient very likely to be followedand to afford the supplements because of proximity to your center
Not sleeve---poor weight loss with sleeve in super obeseNot Banded sleeve---Good weight loss but poor food tolerance since patient is a non vegetarianNot Gastric bypass---Weight loss in super obese have high non response after gastric bypass
and the gastric bypass is technically a more difficult operation than the OAGBNot Banded gastric bypass ndashGood weight loss but a BGBP is a more difficult operation and
the patient will have some food intolerance because of the ring
SURGICAL TREATMENT OPTIONS
At Mohak we perform these standard three operations and their banded modifications
Sleeve Gastrectomy Gastric Bypass OAGBMGB
CHOICE OF PROCEDURE
Evidence based operations performed at MBRSC From 2010 t0 2017---Standardized OperationsLaparoscopic Sleeve Gastrectomybull 90-120 cc Sleevebull 2-5cm from pylorusbull Where a sleeve is indicated but a band is contraindicated or not affordableBanded Sleeve Gastrectomy (BSG) 84 EWL after 60 monthsbull 90-120 cc Sleevebull 2-5cm from pylorusbull Ring 65-75 cmbull At 3-6 cm below GE junctionBanded Gastric bypass (BGBP) 75 EWL 48 monthsbull Create 6mdash7cm long pouchbull 65-75 cm ring at 3-5 cm below GE junction and gt2cm above anastomosisbull Large Gastroenterostomy gt 2cm bull 100cm Roux Limb and 80 cm BP limb for BMIlt50bull 100cm Roux Limb and 150 cm BP limb for BMIgt50Mini-Gastric Bypass (MGB) (OAGB) 79 EWL 60 monthsbull 9-18cm long pouch ~25cm widebull BP Limb length of 180cm BMIlt50Banded Mini-Gastric Bypass(BMGB)(BOAGB)bull 9-18cm long pouch ~25cm widebull Ring 7-75 cmbull BP Limb length of 180cm BMI50
THE MOHAK PROTOCOLStandardized Bariatric and Robotic Surgery Operations
CHOICE OF PROCEDURE
Sleeve Gastrectomy (LSG) or Banded Sleeve Gastrectomy (BSG)bull Non-diabeticsbull No hiatal hernia or GERDbull HO Smokingbull HO alcohol usebull HO PUDbull Abnormal LFTs NASH and early Cirrhosisbull Pts from areas with high incidence of gastric cancer of H pylori infectionbull High risks patients and super obese patients as part of a two-staged operation
Gastric Bypass (LGBP) or Banded Gastric Bypass (BGBP) or Hybrid BGBPMGBbull Have T2DM with HgbA1c lt 8 and duration lt 5 yearsbull Have Hiatal hernia or GERDbull Are Vegetarianbull No nicotine addiction (smoking)bull Have HO Alcohol intake bull Have NASH at surgery-No cirrhosisbull Not likely to come back for follow up andbull Revision operation of Failed Sleeve gastrectomy GBP or MGB
MOHAK ALGORITHM
CHOICE OF PROCEDURE
One Anastomosis Gastric Bypass-Mini-Gastric Bypass (OAGBP-MGB) bull Have T2DM with HgbA1c 8 and durationgt5 yearsbull Have No GERDbull Are Non-vegetarianbull Have poor dentitionbull Most likely to return for follow up at the clinicbull No HO alcohol intakebull No Nicotine addiction (smoking)bull Normal LFTsbull No NASH at surgery or cirrhosisbull Commitment by our program to have 100 follow up of theses patient
Revision Operationbull Sleeve to Banded RY with 100 cm Al limb and 180 cm BP Limbbull MGB to diverted MGB for Reflux Existing BPL and 100cm ALbull MGB to GBP for PCM or reversal to normal anatomy for PCMmdashinterim gastrostomy feedingbull GBP to BGBP with 180cm BP limb for Weight regain or inadequate weight loss BMIlt40bull GBP to BGBP with 300cm common limb for Weight regain or inadequate weight loss BMIgt40
MOHAK ALGORITHM
CHOICE OF PROCEDURE
bull Laparoscopic Gastric Bypass
bull Laparoscopic Sleeve Gastrectomy
bull Divided Mini-Gastric Bypass
bull Biliopancreatic Diversion with DS
bull Single Anastomosis Duodeno-ileostomy
bull Gastric Plication
bull Banded Gastric Plication
bull Endoscopic Gastroplasty
bull Laparoscopic Adjustable Gastric bands
bull Balloon Implantation
bull Ileal interposition
These other operations will be used selectively based on patients needs and the surgeons determination
CHOICE OF PROCEDURE
The MOHAK Guide for Choice of Bariatric Metabolic Surgery Operations
Single Incision Laparoscopic Robotic and Endoscopic approaches are
available at patientsrsquo requests and the discretion of the surgeon
CHOICE OF PROCEDURE
The MOHAK Guide for Choice of Bariatric Metabolic Surgery Operations
Mohak Bariatrics and Robotics Surgery Center Motto
ldquoThe best operation for the patient by a competent surgeon in a well equipped hospital to maximize outcomes with the least amount of risks exposurerdquo
WE ARE ABLE TO CHOOSE THE BEST BARIATRIC METABOLIC PROCEDURE FOR YOUR PATIENT
Good long-term results are our marketing toolSuccessful patients make a lot of referralsbull
CHOICE OF PROCEDURE
The MOHAK Guide for Choice of Bariatric Metabolic Surgery Operations
We offer various treatment modalities for obesity The operation is
determined by the profile of the patient and guided by findings from
analysis of the data from our prospectively maintained database
MOHAK TEAM INDORE INDIA
THANK YOU
THREE YEARS SIX YEARS
THREE YEARS SIX YEARSLess than 50 50-75 above75 Less than 50 50-75 above75
BSG (0) 0 (2) 35 (56) 965 (0) 0 (4) 83 (44) 917
LSG (15)111 (66)474 (53)395 (46)469 (46)469 (9)91
0102030405060708090
100
BSG
LSG
3 YEARSLSG 111BSG 0
FAILURE RATE
6 YEARSLSG 469BSG 0
CHOICE OF PROCEDURE
CHOICE OF PROCEDURE
Bhandari M Mathur W Mishra A MBRSC Course May 2017 Indore India
The Gastric Bypass is the Gold Standard of Bariatric Metabolic Operations
RGBP BGBP
CHOICE OF PROCEDURE
COMPARISON OF BGBP VS STD GBP
Outcome after the operations BGBP STD GBP
Av Initial weight loss 1-3yrs gt77 65-70
Weight loss 4-10 years 70-77 55-65
Resolution of T2DM 80--85 60-80
VomitingSolid Food Intolerance 5-15 lt5
Significant Weight regain 3-7 10-35
Ringband Erosion 0-2 NA
CHOICE OF PROCEDURE
OAGBPMGB
One Anastamosis Gastric BypassMini Gastric Bypass (OAGBMGB)
Simplicity
Repeatability
Minimal Dissection
Reversibility
Exit Strategy
Safety
Minimal Suturing
Short Duration
Short Learning Curve
CHOICE OF PROCEDURE
OAGBSAGBMGB Advantagesbull Easier operation compared to Standard GBPbull Better food tolerancebull More weight loss than standard GBPbull Better weigh Loss Maintenancebull Higher metabolic effect on T2DM and Hyperlipidemiabull Less incidence of internal herniabull More options for revision if needed
Disadvantagesbull Bile reflux gastritis and esophagitisbull Marginal ulcersbull Nutrient deficienciesbull Protein Caloric Malnutrition
Quan Y Huanh A Ye M Efficacy of laproscopic mini gastric bypass for obesity and type 2 diabetes mellitus A systematic review and met-analysis Gastroenterol Res Pract 2015 ID 152852 10155
CHOICE OF PROCEDURE
2015 ndash Review articleVictorzon M et al Scand J Surg 2015 Mar104(1)48-53 Single-anastomosis gastric
bypass better faster and safer
bull The abstracts of 73 articles were reviewed and after removal of case studies duplicates and irrelevant articles 10 articles remained for closer review
bull Several thousand of this operation have been performed for more than 15 years It is claimed to be an easier safer faster and more effective metabolic operation compared to the standard Roux-en-Y gastric bypass The proponents of this operation also claim that this operation is easier to revise and reverse leaving more options compared to the situation after standard bypass in case of failure However there is much controversy surrounding this method mainly concerning the possible harmful and in the long-term even carcinogenic effects of biliopancreaticoduodenal reflux in the gastric pouch
Comment
Several thousands MGBs performed over 15 yrsEasier safer faster amp more effective than
RYGBEasier to revise amp reverse
Controversy regarding carcinogenic effect of BPD reflux
1306
1213
1294
1218
131
1207
114
116
118
12
122
124
126
128
13
132
Before After
BGB LGB MGB
Hemoglobin
RYGB VS Banded RYGB VS OAGBMGB
CHOICE OF PROCEDURE
399
372
394
36
396
352
32
33
34
35
36
37
38
39
4
41
Before After
BGB LGB MGB
Albumin661
644
693
67
685
607
56
58
6
62
64
66
68
7
Before After
BGB LGB MGB
Protein
RYGB VS Banded RYGB VS OAGBMGB
CHOICE OF PROCEDURE
911
87
906
873
909
833
78
8
82
84
86
88
9
92
Before After
BGB LGB MGB
Calcium
CHOICE OF PROCEDURE
RYGB VS Banded RYGB VS OAGBMGB
COMPARISON OF BGBP OAGB VS STD GBP
Outcome after the operations BGBP OAGBP STD GBP
Av Initial weight loss 1-3yrs gt77 gt77 65-70
Weight loss 4-10 years 70-77 70-77 55-65
Resolution of T2DM 80--85 80-90 60-80
VomitingSolid Food Intolerance 5-15 lt5 lt5
Diarrhea and Steatorrhea 1-2A 15-30 NA
Symptomatic Reflux 1-3 3-11 1-3
Marginal Ulcers 3-5 3-5 3-5
Protein Caloric Malnutrition lt1 3-11 lt1
Significant Weight regain 3-10 3-10 10-35
Ringband Erosion 0-1 NA NA
CHOICE OF PROCEDURE
We have enough information currently to enhance the outcome and minimize the risk by matching the operation to the patient
That is the basis forAn Algorithm for Bariatric Metabolic Operations
CHOOSING THE BEST BARIATRIC METABOLIC PROCEDURE FOR THE PATIENT
CHOICE OF PROCEDURE
bull All agesbull With no diabetesbull With low BMI preferably lt40bull With no GERDbull With HO PUDbull With HO or findings of liver diseasebull With Inflammatory bowel diseasebull With dense adhesions from multiple small bowel surgeriesbull Without HO VTEbull In heavy smokers who are not likely to quitbull In gastric cancer endemic areasbull High Risk needing minimal anesthesia and OR timebull High BMI gt 60 as part of a two stage approach
ALGORITHM
LSG BSG
CHOICE OF PROCEDURE
Laparoscopic Sleeve Gastrectomy Or Banded Sleeve Gastrostomy (SGBSD) Indicated for Patients
-All ages-Patients with T2DM lt5years and HbA1-c lt8 C-Peptidegt2 and not on insulin
-Patients with GERD
-ALL BMI ----- -BGBPBMIlt50-- LGBP
Vegetarian (BGBP)
BGBPLGBP
CHOICE OF PROCEDURE
ALGORITHM
Laparoscopic Gastric Bypass(LGBP) or Banded Gastric Bypass(BGBP) Indicated for Patients
bull With Diabetes gt5 years HbA1cgt8 C-Peptide lt2andor on Insulinbull All agesbull All BMI particularly High BMI-gt50bull High risk patients with need for short anesthesia timebull Because it is an easy to perform procedurebull Best tolerated by non Vegetarian
bull GERD Is a contraindicationbull Liver disease is a contraindication
Must be able to follow up patient regularlyPatient must be able to afford the required supplements OAGB
CHOICE OF PROCEDURE
ALGORITHM
OAGBMGB for patients
Sleeve gastrectomy with duodenal bypass(SGDJB) in patients with indication for Gastric Bypass in Gastric Cancer Endemic Areas
As effective as GBPSame weight loss andmetabolic effects as gastric bypass
SG-DJB
CHOICE OF PROCEDURE
ALGORITHM
Sleeve gastrectomy with duodenal bypass(SGDJB) in patients
1Second stage operation for the sleeve gastrectomy
2 Non responders or complications of sleeve gastric bypass or OAGBMGB
BPD-DS SADI SASI SG with enteral bypass
CHOICE OF PROCEDURE
ALGORITHM
BPD-DS SADI SAGI SASI) Indicated for
Areas with high incidence of anemia and very strict vegetarian food habits
CHOICE OF PROCEDURE
ALGORITHM
Sleeve Gastrectomy with gastro-jejunal gastro-ileal or entero-enteral anastomosis
Intra Gastric Balloon ENDOBARRIER
V-BLOC Aspire AssistEndoscopic Plication
For a patient who does not want an intra abdominal gastro-intestinal procedure
CHOICE OF PROCEDURE
Should You Do A Bariatric Metabolic Operation Because That Is What The Patient Wantsrdquo
NOYESmdashIt depends HoweverA bariatric metabolic surgeon should be able to offer the best operation for the patient based on the patientrsquos profile It is good practice to refer the patient to a tertiary center if the surgeon does not offer the operation that meets the patients indication
CHOICE OF PROCEDURE
CHOOSING THE BEST BARIATRIC METABOLIC PROCEDURE FOR THE PATIENT
CHOICE OF PROCEDURE
Case 157 yo Male BMI 57KgM2 T2DM GERD Strict Vegetarian
Algorithm
Gastric bypass-----Preferably Banded gastric bypassmdash------GERD Vegetarian
Not Sleeve because of T2DM GERD and High BMI
Not OAGBMGB because of GERD and probable of protein deficiency
CHOOSING THE BEST BARIATRIC METABOLIC PROCEDURE FOR THE PATIENT
CHOICE OF PROCEDURE
Case 1128 y0 F BMI 42 PCO DUB OSA and HO Migraine headaches
AlgorithmSleeve GastrectomymdashPreferably a Ring banded Sleeve gastrectomy
----No T2DM---No GERDNot Gastric bypass mdash anemia smelly flatus
Not OAGBMGB----Anemia Foul smelling flatus and body odor----Protein deficiency
CHOOSING THE BEST BARIATRIC METABOLIC PROCEDURE FOR THE PATIENT
CHOICE OF PROCEDURE
Case 11137 yo Male BMI 68 OSA OA and a non vegetarian who works at your hospitalReferred by the pulmonologist at your medical Centre
Algorithm
OAGBMGBmdashHigh BMI Non Veg-better food tolerance patient very likely to be followedand to afford the supplements because of proximity to your center
Not sleeve---poor weight loss with sleeve in super obeseNot Banded sleeve---Good weight loss but poor food tolerance since patient is a non vegetarianNot Gastric bypass---Weight loss in super obese have high non response after gastric bypass
and the gastric bypass is technically a more difficult operation than the OAGBNot Banded gastric bypass ndashGood weight loss but a BGBP is a more difficult operation and
the patient will have some food intolerance because of the ring
SURGICAL TREATMENT OPTIONS
At Mohak we perform these standard three operations and their banded modifications
Sleeve Gastrectomy Gastric Bypass OAGBMGB
CHOICE OF PROCEDURE
Evidence based operations performed at MBRSC From 2010 t0 2017---Standardized OperationsLaparoscopic Sleeve Gastrectomybull 90-120 cc Sleevebull 2-5cm from pylorusbull Where a sleeve is indicated but a band is contraindicated or not affordableBanded Sleeve Gastrectomy (BSG) 84 EWL after 60 monthsbull 90-120 cc Sleevebull 2-5cm from pylorusbull Ring 65-75 cmbull At 3-6 cm below GE junctionBanded Gastric bypass (BGBP) 75 EWL 48 monthsbull Create 6mdash7cm long pouchbull 65-75 cm ring at 3-5 cm below GE junction and gt2cm above anastomosisbull Large Gastroenterostomy gt 2cm bull 100cm Roux Limb and 80 cm BP limb for BMIlt50bull 100cm Roux Limb and 150 cm BP limb for BMIgt50Mini-Gastric Bypass (MGB) (OAGB) 79 EWL 60 monthsbull 9-18cm long pouch ~25cm widebull BP Limb length of 180cm BMIlt50Banded Mini-Gastric Bypass(BMGB)(BOAGB)bull 9-18cm long pouch ~25cm widebull Ring 7-75 cmbull BP Limb length of 180cm BMI50
THE MOHAK PROTOCOLStandardized Bariatric and Robotic Surgery Operations
CHOICE OF PROCEDURE
Sleeve Gastrectomy (LSG) or Banded Sleeve Gastrectomy (BSG)bull Non-diabeticsbull No hiatal hernia or GERDbull HO Smokingbull HO alcohol usebull HO PUDbull Abnormal LFTs NASH and early Cirrhosisbull Pts from areas with high incidence of gastric cancer of H pylori infectionbull High risks patients and super obese patients as part of a two-staged operation
Gastric Bypass (LGBP) or Banded Gastric Bypass (BGBP) or Hybrid BGBPMGBbull Have T2DM with HgbA1c lt 8 and duration lt 5 yearsbull Have Hiatal hernia or GERDbull Are Vegetarianbull No nicotine addiction (smoking)bull Have HO Alcohol intake bull Have NASH at surgery-No cirrhosisbull Not likely to come back for follow up andbull Revision operation of Failed Sleeve gastrectomy GBP or MGB
MOHAK ALGORITHM
CHOICE OF PROCEDURE
One Anastomosis Gastric Bypass-Mini-Gastric Bypass (OAGBP-MGB) bull Have T2DM with HgbA1c 8 and durationgt5 yearsbull Have No GERDbull Are Non-vegetarianbull Have poor dentitionbull Most likely to return for follow up at the clinicbull No HO alcohol intakebull No Nicotine addiction (smoking)bull Normal LFTsbull No NASH at surgery or cirrhosisbull Commitment by our program to have 100 follow up of theses patient
Revision Operationbull Sleeve to Banded RY with 100 cm Al limb and 180 cm BP Limbbull MGB to diverted MGB for Reflux Existing BPL and 100cm ALbull MGB to GBP for PCM or reversal to normal anatomy for PCMmdashinterim gastrostomy feedingbull GBP to BGBP with 180cm BP limb for Weight regain or inadequate weight loss BMIlt40bull GBP to BGBP with 300cm common limb for Weight regain or inadequate weight loss BMIgt40
MOHAK ALGORITHM
CHOICE OF PROCEDURE
bull Laparoscopic Gastric Bypass
bull Laparoscopic Sleeve Gastrectomy
bull Divided Mini-Gastric Bypass
bull Biliopancreatic Diversion with DS
bull Single Anastomosis Duodeno-ileostomy
bull Gastric Plication
bull Banded Gastric Plication
bull Endoscopic Gastroplasty
bull Laparoscopic Adjustable Gastric bands
bull Balloon Implantation
bull Ileal interposition
These other operations will be used selectively based on patients needs and the surgeons determination
CHOICE OF PROCEDURE
The MOHAK Guide for Choice of Bariatric Metabolic Surgery Operations
Single Incision Laparoscopic Robotic and Endoscopic approaches are
available at patientsrsquo requests and the discretion of the surgeon
CHOICE OF PROCEDURE
The MOHAK Guide for Choice of Bariatric Metabolic Surgery Operations
Mohak Bariatrics and Robotics Surgery Center Motto
ldquoThe best operation for the patient by a competent surgeon in a well equipped hospital to maximize outcomes with the least amount of risks exposurerdquo
WE ARE ABLE TO CHOOSE THE BEST BARIATRIC METABOLIC PROCEDURE FOR YOUR PATIENT
Good long-term results are our marketing toolSuccessful patients make a lot of referralsbull
CHOICE OF PROCEDURE
The MOHAK Guide for Choice of Bariatric Metabolic Surgery Operations
We offer various treatment modalities for obesity The operation is
determined by the profile of the patient and guided by findings from
analysis of the data from our prospectively maintained database
MOHAK TEAM INDORE INDIA
THANK YOU
CHOICE OF PROCEDURE
Bhandari M Mathur W Mishra A MBRSC Course May 2017 Indore India
The Gastric Bypass is the Gold Standard of Bariatric Metabolic Operations
RGBP BGBP
CHOICE OF PROCEDURE
COMPARISON OF BGBP VS STD GBP
Outcome after the operations BGBP STD GBP
Av Initial weight loss 1-3yrs gt77 65-70
Weight loss 4-10 years 70-77 55-65
Resolution of T2DM 80--85 60-80
VomitingSolid Food Intolerance 5-15 lt5
Significant Weight regain 3-7 10-35
Ringband Erosion 0-2 NA
CHOICE OF PROCEDURE
OAGBPMGB
One Anastamosis Gastric BypassMini Gastric Bypass (OAGBMGB)
Simplicity
Repeatability
Minimal Dissection
Reversibility
Exit Strategy
Safety
Minimal Suturing
Short Duration
Short Learning Curve
CHOICE OF PROCEDURE
OAGBSAGBMGB Advantagesbull Easier operation compared to Standard GBPbull Better food tolerancebull More weight loss than standard GBPbull Better weigh Loss Maintenancebull Higher metabolic effect on T2DM and Hyperlipidemiabull Less incidence of internal herniabull More options for revision if needed
Disadvantagesbull Bile reflux gastritis and esophagitisbull Marginal ulcersbull Nutrient deficienciesbull Protein Caloric Malnutrition
Quan Y Huanh A Ye M Efficacy of laproscopic mini gastric bypass for obesity and type 2 diabetes mellitus A systematic review and met-analysis Gastroenterol Res Pract 2015 ID 152852 10155
CHOICE OF PROCEDURE
2015 ndash Review articleVictorzon M et al Scand J Surg 2015 Mar104(1)48-53 Single-anastomosis gastric
bypass better faster and safer
bull The abstracts of 73 articles were reviewed and after removal of case studies duplicates and irrelevant articles 10 articles remained for closer review
bull Several thousand of this operation have been performed for more than 15 years It is claimed to be an easier safer faster and more effective metabolic operation compared to the standard Roux-en-Y gastric bypass The proponents of this operation also claim that this operation is easier to revise and reverse leaving more options compared to the situation after standard bypass in case of failure However there is much controversy surrounding this method mainly concerning the possible harmful and in the long-term even carcinogenic effects of biliopancreaticoduodenal reflux in the gastric pouch
Comment
Several thousands MGBs performed over 15 yrsEasier safer faster amp more effective than
RYGBEasier to revise amp reverse
Controversy regarding carcinogenic effect of BPD reflux
1306
1213
1294
1218
131
1207
114
116
118
12
122
124
126
128
13
132
Before After
BGB LGB MGB
Hemoglobin
RYGB VS Banded RYGB VS OAGBMGB
CHOICE OF PROCEDURE
399
372
394
36
396
352
32
33
34
35
36
37
38
39
4
41
Before After
BGB LGB MGB
Albumin661
644
693
67
685
607
56
58
6
62
64
66
68
7
Before After
BGB LGB MGB
Protein
RYGB VS Banded RYGB VS OAGBMGB
CHOICE OF PROCEDURE
911
87
906
873
909
833
78
8
82
84
86
88
9
92
Before After
BGB LGB MGB
Calcium
CHOICE OF PROCEDURE
RYGB VS Banded RYGB VS OAGBMGB
COMPARISON OF BGBP OAGB VS STD GBP
Outcome after the operations BGBP OAGBP STD GBP
Av Initial weight loss 1-3yrs gt77 gt77 65-70
Weight loss 4-10 years 70-77 70-77 55-65
Resolution of T2DM 80--85 80-90 60-80
VomitingSolid Food Intolerance 5-15 lt5 lt5
Diarrhea and Steatorrhea 1-2A 15-30 NA
Symptomatic Reflux 1-3 3-11 1-3
Marginal Ulcers 3-5 3-5 3-5
Protein Caloric Malnutrition lt1 3-11 lt1
Significant Weight regain 3-10 3-10 10-35
Ringband Erosion 0-1 NA NA
CHOICE OF PROCEDURE
We have enough information currently to enhance the outcome and minimize the risk by matching the operation to the patient
That is the basis forAn Algorithm for Bariatric Metabolic Operations
CHOOSING THE BEST BARIATRIC METABOLIC PROCEDURE FOR THE PATIENT
CHOICE OF PROCEDURE
bull All agesbull With no diabetesbull With low BMI preferably lt40bull With no GERDbull With HO PUDbull With HO or findings of liver diseasebull With Inflammatory bowel diseasebull With dense adhesions from multiple small bowel surgeriesbull Without HO VTEbull In heavy smokers who are not likely to quitbull In gastric cancer endemic areasbull High Risk needing minimal anesthesia and OR timebull High BMI gt 60 as part of a two stage approach
ALGORITHM
LSG BSG
CHOICE OF PROCEDURE
Laparoscopic Sleeve Gastrectomy Or Banded Sleeve Gastrostomy (SGBSD) Indicated for Patients
-All ages-Patients with T2DM lt5years and HbA1-c lt8 C-Peptidegt2 and not on insulin
-Patients with GERD
-ALL BMI ----- -BGBPBMIlt50-- LGBP
Vegetarian (BGBP)
BGBPLGBP
CHOICE OF PROCEDURE
ALGORITHM
Laparoscopic Gastric Bypass(LGBP) or Banded Gastric Bypass(BGBP) Indicated for Patients
bull With Diabetes gt5 years HbA1cgt8 C-Peptide lt2andor on Insulinbull All agesbull All BMI particularly High BMI-gt50bull High risk patients with need for short anesthesia timebull Because it is an easy to perform procedurebull Best tolerated by non Vegetarian
bull GERD Is a contraindicationbull Liver disease is a contraindication
Must be able to follow up patient regularlyPatient must be able to afford the required supplements OAGB
CHOICE OF PROCEDURE
ALGORITHM
OAGBMGB for patients
Sleeve gastrectomy with duodenal bypass(SGDJB) in patients with indication for Gastric Bypass in Gastric Cancer Endemic Areas
As effective as GBPSame weight loss andmetabolic effects as gastric bypass
SG-DJB
CHOICE OF PROCEDURE
ALGORITHM
Sleeve gastrectomy with duodenal bypass(SGDJB) in patients
1Second stage operation for the sleeve gastrectomy
2 Non responders or complications of sleeve gastric bypass or OAGBMGB
BPD-DS SADI SASI SG with enteral bypass
CHOICE OF PROCEDURE
ALGORITHM
BPD-DS SADI SAGI SASI) Indicated for
Areas with high incidence of anemia and very strict vegetarian food habits
CHOICE OF PROCEDURE
ALGORITHM
Sleeve Gastrectomy with gastro-jejunal gastro-ileal or entero-enteral anastomosis
Intra Gastric Balloon ENDOBARRIER
V-BLOC Aspire AssistEndoscopic Plication
For a patient who does not want an intra abdominal gastro-intestinal procedure
CHOICE OF PROCEDURE
Should You Do A Bariatric Metabolic Operation Because That Is What The Patient Wantsrdquo
NOYESmdashIt depends HoweverA bariatric metabolic surgeon should be able to offer the best operation for the patient based on the patientrsquos profile It is good practice to refer the patient to a tertiary center if the surgeon does not offer the operation that meets the patients indication
CHOICE OF PROCEDURE
CHOOSING THE BEST BARIATRIC METABOLIC PROCEDURE FOR THE PATIENT
CHOICE OF PROCEDURE
Case 157 yo Male BMI 57KgM2 T2DM GERD Strict Vegetarian
Algorithm
Gastric bypass-----Preferably Banded gastric bypassmdash------GERD Vegetarian
Not Sleeve because of T2DM GERD and High BMI
Not OAGBMGB because of GERD and probable of protein deficiency
CHOOSING THE BEST BARIATRIC METABOLIC PROCEDURE FOR THE PATIENT
CHOICE OF PROCEDURE
Case 1128 y0 F BMI 42 PCO DUB OSA and HO Migraine headaches
AlgorithmSleeve GastrectomymdashPreferably a Ring banded Sleeve gastrectomy
----No T2DM---No GERDNot Gastric bypass mdash anemia smelly flatus
Not OAGBMGB----Anemia Foul smelling flatus and body odor----Protein deficiency
CHOOSING THE BEST BARIATRIC METABOLIC PROCEDURE FOR THE PATIENT
CHOICE OF PROCEDURE
Case 11137 yo Male BMI 68 OSA OA and a non vegetarian who works at your hospitalReferred by the pulmonologist at your medical Centre
Algorithm
OAGBMGBmdashHigh BMI Non Veg-better food tolerance patient very likely to be followedand to afford the supplements because of proximity to your center
Not sleeve---poor weight loss with sleeve in super obeseNot Banded sleeve---Good weight loss but poor food tolerance since patient is a non vegetarianNot Gastric bypass---Weight loss in super obese have high non response after gastric bypass
and the gastric bypass is technically a more difficult operation than the OAGBNot Banded gastric bypass ndashGood weight loss but a BGBP is a more difficult operation and
the patient will have some food intolerance because of the ring
SURGICAL TREATMENT OPTIONS
At Mohak we perform these standard three operations and their banded modifications
Sleeve Gastrectomy Gastric Bypass OAGBMGB
CHOICE OF PROCEDURE
Evidence based operations performed at MBRSC From 2010 t0 2017---Standardized OperationsLaparoscopic Sleeve Gastrectomybull 90-120 cc Sleevebull 2-5cm from pylorusbull Where a sleeve is indicated but a band is contraindicated or not affordableBanded Sleeve Gastrectomy (BSG) 84 EWL after 60 monthsbull 90-120 cc Sleevebull 2-5cm from pylorusbull Ring 65-75 cmbull At 3-6 cm below GE junctionBanded Gastric bypass (BGBP) 75 EWL 48 monthsbull Create 6mdash7cm long pouchbull 65-75 cm ring at 3-5 cm below GE junction and gt2cm above anastomosisbull Large Gastroenterostomy gt 2cm bull 100cm Roux Limb and 80 cm BP limb for BMIlt50bull 100cm Roux Limb and 150 cm BP limb for BMIgt50Mini-Gastric Bypass (MGB) (OAGB) 79 EWL 60 monthsbull 9-18cm long pouch ~25cm widebull BP Limb length of 180cm BMIlt50Banded Mini-Gastric Bypass(BMGB)(BOAGB)bull 9-18cm long pouch ~25cm widebull Ring 7-75 cmbull BP Limb length of 180cm BMI50
THE MOHAK PROTOCOLStandardized Bariatric and Robotic Surgery Operations
CHOICE OF PROCEDURE
Sleeve Gastrectomy (LSG) or Banded Sleeve Gastrectomy (BSG)bull Non-diabeticsbull No hiatal hernia or GERDbull HO Smokingbull HO alcohol usebull HO PUDbull Abnormal LFTs NASH and early Cirrhosisbull Pts from areas with high incidence of gastric cancer of H pylori infectionbull High risks patients and super obese patients as part of a two-staged operation
Gastric Bypass (LGBP) or Banded Gastric Bypass (BGBP) or Hybrid BGBPMGBbull Have T2DM with HgbA1c lt 8 and duration lt 5 yearsbull Have Hiatal hernia or GERDbull Are Vegetarianbull No nicotine addiction (smoking)bull Have HO Alcohol intake bull Have NASH at surgery-No cirrhosisbull Not likely to come back for follow up andbull Revision operation of Failed Sleeve gastrectomy GBP or MGB
MOHAK ALGORITHM
CHOICE OF PROCEDURE
One Anastomosis Gastric Bypass-Mini-Gastric Bypass (OAGBP-MGB) bull Have T2DM with HgbA1c 8 and durationgt5 yearsbull Have No GERDbull Are Non-vegetarianbull Have poor dentitionbull Most likely to return for follow up at the clinicbull No HO alcohol intakebull No Nicotine addiction (smoking)bull Normal LFTsbull No NASH at surgery or cirrhosisbull Commitment by our program to have 100 follow up of theses patient
Revision Operationbull Sleeve to Banded RY with 100 cm Al limb and 180 cm BP Limbbull MGB to diverted MGB for Reflux Existing BPL and 100cm ALbull MGB to GBP for PCM or reversal to normal anatomy for PCMmdashinterim gastrostomy feedingbull GBP to BGBP with 180cm BP limb for Weight regain or inadequate weight loss BMIlt40bull GBP to BGBP with 300cm common limb for Weight regain or inadequate weight loss BMIgt40
MOHAK ALGORITHM
CHOICE OF PROCEDURE
bull Laparoscopic Gastric Bypass
bull Laparoscopic Sleeve Gastrectomy
bull Divided Mini-Gastric Bypass
bull Biliopancreatic Diversion with DS
bull Single Anastomosis Duodeno-ileostomy
bull Gastric Plication
bull Banded Gastric Plication
bull Endoscopic Gastroplasty
bull Laparoscopic Adjustable Gastric bands
bull Balloon Implantation
bull Ileal interposition
These other operations will be used selectively based on patients needs and the surgeons determination
CHOICE OF PROCEDURE
The MOHAK Guide for Choice of Bariatric Metabolic Surgery Operations
Single Incision Laparoscopic Robotic and Endoscopic approaches are
available at patientsrsquo requests and the discretion of the surgeon
CHOICE OF PROCEDURE
The MOHAK Guide for Choice of Bariatric Metabolic Surgery Operations
Mohak Bariatrics and Robotics Surgery Center Motto
ldquoThe best operation for the patient by a competent surgeon in a well equipped hospital to maximize outcomes with the least amount of risks exposurerdquo
WE ARE ABLE TO CHOOSE THE BEST BARIATRIC METABOLIC PROCEDURE FOR YOUR PATIENT
Good long-term results are our marketing toolSuccessful patients make a lot of referralsbull
CHOICE OF PROCEDURE
The MOHAK Guide for Choice of Bariatric Metabolic Surgery Operations
We offer various treatment modalities for obesity The operation is
determined by the profile of the patient and guided by findings from
analysis of the data from our prospectively maintained database
MOHAK TEAM INDORE INDIA
THANK YOU
Bhandari M Mathur W Mishra A MBRSC Course May 2017 Indore India
The Gastric Bypass is the Gold Standard of Bariatric Metabolic Operations
RGBP BGBP
CHOICE OF PROCEDURE
COMPARISON OF BGBP VS STD GBP
Outcome after the operations BGBP STD GBP
Av Initial weight loss 1-3yrs gt77 65-70
Weight loss 4-10 years 70-77 55-65
Resolution of T2DM 80--85 60-80
VomitingSolid Food Intolerance 5-15 lt5
Significant Weight regain 3-7 10-35
Ringband Erosion 0-2 NA
CHOICE OF PROCEDURE
OAGBPMGB
One Anastamosis Gastric BypassMini Gastric Bypass (OAGBMGB)
Simplicity
Repeatability
Minimal Dissection
Reversibility
Exit Strategy
Safety
Minimal Suturing
Short Duration
Short Learning Curve
CHOICE OF PROCEDURE
OAGBSAGBMGB Advantagesbull Easier operation compared to Standard GBPbull Better food tolerancebull More weight loss than standard GBPbull Better weigh Loss Maintenancebull Higher metabolic effect on T2DM and Hyperlipidemiabull Less incidence of internal herniabull More options for revision if needed
Disadvantagesbull Bile reflux gastritis and esophagitisbull Marginal ulcersbull Nutrient deficienciesbull Protein Caloric Malnutrition
Quan Y Huanh A Ye M Efficacy of laproscopic mini gastric bypass for obesity and type 2 diabetes mellitus A systematic review and met-analysis Gastroenterol Res Pract 2015 ID 152852 10155
CHOICE OF PROCEDURE
2015 ndash Review articleVictorzon M et al Scand J Surg 2015 Mar104(1)48-53 Single-anastomosis gastric
bypass better faster and safer
bull The abstracts of 73 articles were reviewed and after removal of case studies duplicates and irrelevant articles 10 articles remained for closer review
bull Several thousand of this operation have been performed for more than 15 years It is claimed to be an easier safer faster and more effective metabolic operation compared to the standard Roux-en-Y gastric bypass The proponents of this operation also claim that this operation is easier to revise and reverse leaving more options compared to the situation after standard bypass in case of failure However there is much controversy surrounding this method mainly concerning the possible harmful and in the long-term even carcinogenic effects of biliopancreaticoduodenal reflux in the gastric pouch
Comment
Several thousands MGBs performed over 15 yrsEasier safer faster amp more effective than
RYGBEasier to revise amp reverse
Controversy regarding carcinogenic effect of BPD reflux
1306
1213
1294
1218
131
1207
114
116
118
12
122
124
126
128
13
132
Before After
BGB LGB MGB
Hemoglobin
RYGB VS Banded RYGB VS OAGBMGB
CHOICE OF PROCEDURE
399
372
394
36
396
352
32
33
34
35
36
37
38
39
4
41
Before After
BGB LGB MGB
Albumin661
644
693
67
685
607
56
58
6
62
64
66
68
7
Before After
BGB LGB MGB
Protein
RYGB VS Banded RYGB VS OAGBMGB
CHOICE OF PROCEDURE
911
87
906
873
909
833
78
8
82
84
86
88
9
92
Before After
BGB LGB MGB
Calcium
CHOICE OF PROCEDURE
RYGB VS Banded RYGB VS OAGBMGB
COMPARISON OF BGBP OAGB VS STD GBP
Outcome after the operations BGBP OAGBP STD GBP
Av Initial weight loss 1-3yrs gt77 gt77 65-70
Weight loss 4-10 years 70-77 70-77 55-65
Resolution of T2DM 80--85 80-90 60-80
VomitingSolid Food Intolerance 5-15 lt5 lt5
Diarrhea and Steatorrhea 1-2A 15-30 NA
Symptomatic Reflux 1-3 3-11 1-3
Marginal Ulcers 3-5 3-5 3-5
Protein Caloric Malnutrition lt1 3-11 lt1
Significant Weight regain 3-10 3-10 10-35
Ringband Erosion 0-1 NA NA
CHOICE OF PROCEDURE
We have enough information currently to enhance the outcome and minimize the risk by matching the operation to the patient
That is the basis forAn Algorithm for Bariatric Metabolic Operations
CHOOSING THE BEST BARIATRIC METABOLIC PROCEDURE FOR THE PATIENT
CHOICE OF PROCEDURE
bull All agesbull With no diabetesbull With low BMI preferably lt40bull With no GERDbull With HO PUDbull With HO or findings of liver diseasebull With Inflammatory bowel diseasebull With dense adhesions from multiple small bowel surgeriesbull Without HO VTEbull In heavy smokers who are not likely to quitbull In gastric cancer endemic areasbull High Risk needing minimal anesthesia and OR timebull High BMI gt 60 as part of a two stage approach
ALGORITHM
LSG BSG
CHOICE OF PROCEDURE
Laparoscopic Sleeve Gastrectomy Or Banded Sleeve Gastrostomy (SGBSD) Indicated for Patients
-All ages-Patients with T2DM lt5years and HbA1-c lt8 C-Peptidegt2 and not on insulin
-Patients with GERD
-ALL BMI ----- -BGBPBMIlt50-- LGBP
Vegetarian (BGBP)
BGBPLGBP
CHOICE OF PROCEDURE
ALGORITHM
Laparoscopic Gastric Bypass(LGBP) or Banded Gastric Bypass(BGBP) Indicated for Patients
bull With Diabetes gt5 years HbA1cgt8 C-Peptide lt2andor on Insulinbull All agesbull All BMI particularly High BMI-gt50bull High risk patients with need for short anesthesia timebull Because it is an easy to perform procedurebull Best tolerated by non Vegetarian
bull GERD Is a contraindicationbull Liver disease is a contraindication
Must be able to follow up patient regularlyPatient must be able to afford the required supplements OAGB
CHOICE OF PROCEDURE
ALGORITHM
OAGBMGB for patients
Sleeve gastrectomy with duodenal bypass(SGDJB) in patients with indication for Gastric Bypass in Gastric Cancer Endemic Areas
As effective as GBPSame weight loss andmetabolic effects as gastric bypass
SG-DJB
CHOICE OF PROCEDURE
ALGORITHM
Sleeve gastrectomy with duodenal bypass(SGDJB) in patients
1Second stage operation for the sleeve gastrectomy
2 Non responders or complications of sleeve gastric bypass or OAGBMGB
BPD-DS SADI SASI SG with enteral bypass
CHOICE OF PROCEDURE
ALGORITHM
BPD-DS SADI SAGI SASI) Indicated for
Areas with high incidence of anemia and very strict vegetarian food habits
CHOICE OF PROCEDURE
ALGORITHM
Sleeve Gastrectomy with gastro-jejunal gastro-ileal or entero-enteral anastomosis
Intra Gastric Balloon ENDOBARRIER
V-BLOC Aspire AssistEndoscopic Plication
For a patient who does not want an intra abdominal gastro-intestinal procedure
CHOICE OF PROCEDURE
Should You Do A Bariatric Metabolic Operation Because That Is What The Patient Wantsrdquo
NOYESmdashIt depends HoweverA bariatric metabolic surgeon should be able to offer the best operation for the patient based on the patientrsquos profile It is good practice to refer the patient to a tertiary center if the surgeon does not offer the operation that meets the patients indication
CHOICE OF PROCEDURE
CHOOSING THE BEST BARIATRIC METABOLIC PROCEDURE FOR THE PATIENT
CHOICE OF PROCEDURE
Case 157 yo Male BMI 57KgM2 T2DM GERD Strict Vegetarian
Algorithm
Gastric bypass-----Preferably Banded gastric bypassmdash------GERD Vegetarian
Not Sleeve because of T2DM GERD and High BMI
Not OAGBMGB because of GERD and probable of protein deficiency
CHOOSING THE BEST BARIATRIC METABOLIC PROCEDURE FOR THE PATIENT
CHOICE OF PROCEDURE
Case 1128 y0 F BMI 42 PCO DUB OSA and HO Migraine headaches
AlgorithmSleeve GastrectomymdashPreferably a Ring banded Sleeve gastrectomy
----No T2DM---No GERDNot Gastric bypass mdash anemia smelly flatus
Not OAGBMGB----Anemia Foul smelling flatus and body odor----Protein deficiency
CHOOSING THE BEST BARIATRIC METABOLIC PROCEDURE FOR THE PATIENT
CHOICE OF PROCEDURE
Case 11137 yo Male BMI 68 OSA OA and a non vegetarian who works at your hospitalReferred by the pulmonologist at your medical Centre
Algorithm
OAGBMGBmdashHigh BMI Non Veg-better food tolerance patient very likely to be followedand to afford the supplements because of proximity to your center
Not sleeve---poor weight loss with sleeve in super obeseNot Banded sleeve---Good weight loss but poor food tolerance since patient is a non vegetarianNot Gastric bypass---Weight loss in super obese have high non response after gastric bypass
and the gastric bypass is technically a more difficult operation than the OAGBNot Banded gastric bypass ndashGood weight loss but a BGBP is a more difficult operation and
the patient will have some food intolerance because of the ring
SURGICAL TREATMENT OPTIONS
At Mohak we perform these standard three operations and their banded modifications
Sleeve Gastrectomy Gastric Bypass OAGBMGB
CHOICE OF PROCEDURE
Evidence based operations performed at MBRSC From 2010 t0 2017---Standardized OperationsLaparoscopic Sleeve Gastrectomybull 90-120 cc Sleevebull 2-5cm from pylorusbull Where a sleeve is indicated but a band is contraindicated or not affordableBanded Sleeve Gastrectomy (BSG) 84 EWL after 60 monthsbull 90-120 cc Sleevebull 2-5cm from pylorusbull Ring 65-75 cmbull At 3-6 cm below GE junctionBanded Gastric bypass (BGBP) 75 EWL 48 monthsbull Create 6mdash7cm long pouchbull 65-75 cm ring at 3-5 cm below GE junction and gt2cm above anastomosisbull Large Gastroenterostomy gt 2cm bull 100cm Roux Limb and 80 cm BP limb for BMIlt50bull 100cm Roux Limb and 150 cm BP limb for BMIgt50Mini-Gastric Bypass (MGB) (OAGB) 79 EWL 60 monthsbull 9-18cm long pouch ~25cm widebull BP Limb length of 180cm BMIlt50Banded Mini-Gastric Bypass(BMGB)(BOAGB)bull 9-18cm long pouch ~25cm widebull Ring 7-75 cmbull BP Limb length of 180cm BMI50
THE MOHAK PROTOCOLStandardized Bariatric and Robotic Surgery Operations
CHOICE OF PROCEDURE
Sleeve Gastrectomy (LSG) or Banded Sleeve Gastrectomy (BSG)bull Non-diabeticsbull No hiatal hernia or GERDbull HO Smokingbull HO alcohol usebull HO PUDbull Abnormal LFTs NASH and early Cirrhosisbull Pts from areas with high incidence of gastric cancer of H pylori infectionbull High risks patients and super obese patients as part of a two-staged operation
Gastric Bypass (LGBP) or Banded Gastric Bypass (BGBP) or Hybrid BGBPMGBbull Have T2DM with HgbA1c lt 8 and duration lt 5 yearsbull Have Hiatal hernia or GERDbull Are Vegetarianbull No nicotine addiction (smoking)bull Have HO Alcohol intake bull Have NASH at surgery-No cirrhosisbull Not likely to come back for follow up andbull Revision operation of Failed Sleeve gastrectomy GBP or MGB
MOHAK ALGORITHM
CHOICE OF PROCEDURE
One Anastomosis Gastric Bypass-Mini-Gastric Bypass (OAGBP-MGB) bull Have T2DM with HgbA1c 8 and durationgt5 yearsbull Have No GERDbull Are Non-vegetarianbull Have poor dentitionbull Most likely to return for follow up at the clinicbull No HO alcohol intakebull No Nicotine addiction (smoking)bull Normal LFTsbull No NASH at surgery or cirrhosisbull Commitment by our program to have 100 follow up of theses patient
Revision Operationbull Sleeve to Banded RY with 100 cm Al limb and 180 cm BP Limbbull MGB to diverted MGB for Reflux Existing BPL and 100cm ALbull MGB to GBP for PCM or reversal to normal anatomy for PCMmdashinterim gastrostomy feedingbull GBP to BGBP with 180cm BP limb for Weight regain or inadequate weight loss BMIlt40bull GBP to BGBP with 300cm common limb for Weight regain or inadequate weight loss BMIgt40
MOHAK ALGORITHM
CHOICE OF PROCEDURE
bull Laparoscopic Gastric Bypass
bull Laparoscopic Sleeve Gastrectomy
bull Divided Mini-Gastric Bypass
bull Biliopancreatic Diversion with DS
bull Single Anastomosis Duodeno-ileostomy
bull Gastric Plication
bull Banded Gastric Plication
bull Endoscopic Gastroplasty
bull Laparoscopic Adjustable Gastric bands
bull Balloon Implantation
bull Ileal interposition
These other operations will be used selectively based on patients needs and the surgeons determination
CHOICE OF PROCEDURE
The MOHAK Guide for Choice of Bariatric Metabolic Surgery Operations
Single Incision Laparoscopic Robotic and Endoscopic approaches are
available at patientsrsquo requests and the discretion of the surgeon
CHOICE OF PROCEDURE
The MOHAK Guide for Choice of Bariatric Metabolic Surgery Operations
Mohak Bariatrics and Robotics Surgery Center Motto
ldquoThe best operation for the patient by a competent surgeon in a well equipped hospital to maximize outcomes with the least amount of risks exposurerdquo
WE ARE ABLE TO CHOOSE THE BEST BARIATRIC METABOLIC PROCEDURE FOR YOUR PATIENT
Good long-term results are our marketing toolSuccessful patients make a lot of referralsbull
CHOICE OF PROCEDURE
The MOHAK Guide for Choice of Bariatric Metabolic Surgery Operations
We offer various treatment modalities for obesity The operation is
determined by the profile of the patient and guided by findings from
analysis of the data from our prospectively maintained database
MOHAK TEAM INDORE INDIA
THANK YOU
COMPARISON OF BGBP VS STD GBP
Outcome after the operations BGBP STD GBP
Av Initial weight loss 1-3yrs gt77 65-70
Weight loss 4-10 years 70-77 55-65
Resolution of T2DM 80--85 60-80
VomitingSolid Food Intolerance 5-15 lt5
Significant Weight regain 3-7 10-35
Ringband Erosion 0-2 NA
CHOICE OF PROCEDURE
OAGBPMGB
One Anastamosis Gastric BypassMini Gastric Bypass (OAGBMGB)
Simplicity
Repeatability
Minimal Dissection
Reversibility
Exit Strategy
Safety
Minimal Suturing
Short Duration
Short Learning Curve
CHOICE OF PROCEDURE
OAGBSAGBMGB Advantagesbull Easier operation compared to Standard GBPbull Better food tolerancebull More weight loss than standard GBPbull Better weigh Loss Maintenancebull Higher metabolic effect on T2DM and Hyperlipidemiabull Less incidence of internal herniabull More options for revision if needed
Disadvantagesbull Bile reflux gastritis and esophagitisbull Marginal ulcersbull Nutrient deficienciesbull Protein Caloric Malnutrition
Quan Y Huanh A Ye M Efficacy of laproscopic mini gastric bypass for obesity and type 2 diabetes mellitus A systematic review and met-analysis Gastroenterol Res Pract 2015 ID 152852 10155
CHOICE OF PROCEDURE
2015 ndash Review articleVictorzon M et al Scand J Surg 2015 Mar104(1)48-53 Single-anastomosis gastric
bypass better faster and safer
bull The abstracts of 73 articles were reviewed and after removal of case studies duplicates and irrelevant articles 10 articles remained for closer review
bull Several thousand of this operation have been performed for more than 15 years It is claimed to be an easier safer faster and more effective metabolic operation compared to the standard Roux-en-Y gastric bypass The proponents of this operation also claim that this operation is easier to revise and reverse leaving more options compared to the situation after standard bypass in case of failure However there is much controversy surrounding this method mainly concerning the possible harmful and in the long-term even carcinogenic effects of biliopancreaticoduodenal reflux in the gastric pouch
Comment
Several thousands MGBs performed over 15 yrsEasier safer faster amp more effective than
RYGBEasier to revise amp reverse
Controversy regarding carcinogenic effect of BPD reflux
1306
1213
1294
1218
131
1207
114
116
118
12
122
124
126
128
13
132
Before After
BGB LGB MGB
Hemoglobin
RYGB VS Banded RYGB VS OAGBMGB
CHOICE OF PROCEDURE
399
372
394
36
396
352
32
33
34
35
36
37
38
39
4
41
Before After
BGB LGB MGB
Albumin661
644
693
67
685
607
56
58
6
62
64
66
68
7
Before After
BGB LGB MGB
Protein
RYGB VS Banded RYGB VS OAGBMGB
CHOICE OF PROCEDURE
911
87
906
873
909
833
78
8
82
84
86
88
9
92
Before After
BGB LGB MGB
Calcium
CHOICE OF PROCEDURE
RYGB VS Banded RYGB VS OAGBMGB
COMPARISON OF BGBP OAGB VS STD GBP
Outcome after the operations BGBP OAGBP STD GBP
Av Initial weight loss 1-3yrs gt77 gt77 65-70
Weight loss 4-10 years 70-77 70-77 55-65
Resolution of T2DM 80--85 80-90 60-80
VomitingSolid Food Intolerance 5-15 lt5 lt5
Diarrhea and Steatorrhea 1-2A 15-30 NA
Symptomatic Reflux 1-3 3-11 1-3
Marginal Ulcers 3-5 3-5 3-5
Protein Caloric Malnutrition lt1 3-11 lt1
Significant Weight regain 3-10 3-10 10-35
Ringband Erosion 0-1 NA NA
CHOICE OF PROCEDURE
We have enough information currently to enhance the outcome and minimize the risk by matching the operation to the patient
That is the basis forAn Algorithm for Bariatric Metabolic Operations
CHOOSING THE BEST BARIATRIC METABOLIC PROCEDURE FOR THE PATIENT
CHOICE OF PROCEDURE
bull All agesbull With no diabetesbull With low BMI preferably lt40bull With no GERDbull With HO PUDbull With HO or findings of liver diseasebull With Inflammatory bowel diseasebull With dense adhesions from multiple small bowel surgeriesbull Without HO VTEbull In heavy smokers who are not likely to quitbull In gastric cancer endemic areasbull High Risk needing minimal anesthesia and OR timebull High BMI gt 60 as part of a two stage approach
ALGORITHM
LSG BSG
CHOICE OF PROCEDURE
Laparoscopic Sleeve Gastrectomy Or Banded Sleeve Gastrostomy (SGBSD) Indicated for Patients
-All ages-Patients with T2DM lt5years and HbA1-c lt8 C-Peptidegt2 and not on insulin
-Patients with GERD
-ALL BMI ----- -BGBPBMIlt50-- LGBP
Vegetarian (BGBP)
BGBPLGBP
CHOICE OF PROCEDURE
ALGORITHM
Laparoscopic Gastric Bypass(LGBP) or Banded Gastric Bypass(BGBP) Indicated for Patients
bull With Diabetes gt5 years HbA1cgt8 C-Peptide lt2andor on Insulinbull All agesbull All BMI particularly High BMI-gt50bull High risk patients with need for short anesthesia timebull Because it is an easy to perform procedurebull Best tolerated by non Vegetarian
bull GERD Is a contraindicationbull Liver disease is a contraindication
Must be able to follow up patient regularlyPatient must be able to afford the required supplements OAGB
CHOICE OF PROCEDURE
ALGORITHM
OAGBMGB for patients
Sleeve gastrectomy with duodenal bypass(SGDJB) in patients with indication for Gastric Bypass in Gastric Cancer Endemic Areas
As effective as GBPSame weight loss andmetabolic effects as gastric bypass
SG-DJB
CHOICE OF PROCEDURE
ALGORITHM
Sleeve gastrectomy with duodenal bypass(SGDJB) in patients
1Second stage operation for the sleeve gastrectomy
2 Non responders or complications of sleeve gastric bypass or OAGBMGB
BPD-DS SADI SASI SG with enteral bypass
CHOICE OF PROCEDURE
ALGORITHM
BPD-DS SADI SAGI SASI) Indicated for
Areas with high incidence of anemia and very strict vegetarian food habits
CHOICE OF PROCEDURE
ALGORITHM
Sleeve Gastrectomy with gastro-jejunal gastro-ileal or entero-enteral anastomosis
Intra Gastric Balloon ENDOBARRIER
V-BLOC Aspire AssistEndoscopic Plication
For a patient who does not want an intra abdominal gastro-intestinal procedure
CHOICE OF PROCEDURE
Should You Do A Bariatric Metabolic Operation Because That Is What The Patient Wantsrdquo
NOYESmdashIt depends HoweverA bariatric metabolic surgeon should be able to offer the best operation for the patient based on the patientrsquos profile It is good practice to refer the patient to a tertiary center if the surgeon does not offer the operation that meets the patients indication
CHOICE OF PROCEDURE
CHOOSING THE BEST BARIATRIC METABOLIC PROCEDURE FOR THE PATIENT
CHOICE OF PROCEDURE
Case 157 yo Male BMI 57KgM2 T2DM GERD Strict Vegetarian
Algorithm
Gastric bypass-----Preferably Banded gastric bypassmdash------GERD Vegetarian
Not Sleeve because of T2DM GERD and High BMI
Not OAGBMGB because of GERD and probable of protein deficiency
CHOOSING THE BEST BARIATRIC METABOLIC PROCEDURE FOR THE PATIENT
CHOICE OF PROCEDURE
Case 1128 y0 F BMI 42 PCO DUB OSA and HO Migraine headaches
AlgorithmSleeve GastrectomymdashPreferably a Ring banded Sleeve gastrectomy
----No T2DM---No GERDNot Gastric bypass mdash anemia smelly flatus
Not OAGBMGB----Anemia Foul smelling flatus and body odor----Protein deficiency
CHOOSING THE BEST BARIATRIC METABOLIC PROCEDURE FOR THE PATIENT
CHOICE OF PROCEDURE
Case 11137 yo Male BMI 68 OSA OA and a non vegetarian who works at your hospitalReferred by the pulmonologist at your medical Centre
Algorithm
OAGBMGBmdashHigh BMI Non Veg-better food tolerance patient very likely to be followedand to afford the supplements because of proximity to your center
Not sleeve---poor weight loss with sleeve in super obeseNot Banded sleeve---Good weight loss but poor food tolerance since patient is a non vegetarianNot Gastric bypass---Weight loss in super obese have high non response after gastric bypass
and the gastric bypass is technically a more difficult operation than the OAGBNot Banded gastric bypass ndashGood weight loss but a BGBP is a more difficult operation and
the patient will have some food intolerance because of the ring
SURGICAL TREATMENT OPTIONS
At Mohak we perform these standard three operations and their banded modifications
Sleeve Gastrectomy Gastric Bypass OAGBMGB
CHOICE OF PROCEDURE
Evidence based operations performed at MBRSC From 2010 t0 2017---Standardized OperationsLaparoscopic Sleeve Gastrectomybull 90-120 cc Sleevebull 2-5cm from pylorusbull Where a sleeve is indicated but a band is contraindicated or not affordableBanded Sleeve Gastrectomy (BSG) 84 EWL after 60 monthsbull 90-120 cc Sleevebull 2-5cm from pylorusbull Ring 65-75 cmbull At 3-6 cm below GE junctionBanded Gastric bypass (BGBP) 75 EWL 48 monthsbull Create 6mdash7cm long pouchbull 65-75 cm ring at 3-5 cm below GE junction and gt2cm above anastomosisbull Large Gastroenterostomy gt 2cm bull 100cm Roux Limb and 80 cm BP limb for BMIlt50bull 100cm Roux Limb and 150 cm BP limb for BMIgt50Mini-Gastric Bypass (MGB) (OAGB) 79 EWL 60 monthsbull 9-18cm long pouch ~25cm widebull BP Limb length of 180cm BMIlt50Banded Mini-Gastric Bypass(BMGB)(BOAGB)bull 9-18cm long pouch ~25cm widebull Ring 7-75 cmbull BP Limb length of 180cm BMI50
THE MOHAK PROTOCOLStandardized Bariatric and Robotic Surgery Operations
CHOICE OF PROCEDURE
Sleeve Gastrectomy (LSG) or Banded Sleeve Gastrectomy (BSG)bull Non-diabeticsbull No hiatal hernia or GERDbull HO Smokingbull HO alcohol usebull HO PUDbull Abnormal LFTs NASH and early Cirrhosisbull Pts from areas with high incidence of gastric cancer of H pylori infectionbull High risks patients and super obese patients as part of a two-staged operation
Gastric Bypass (LGBP) or Banded Gastric Bypass (BGBP) or Hybrid BGBPMGBbull Have T2DM with HgbA1c lt 8 and duration lt 5 yearsbull Have Hiatal hernia or GERDbull Are Vegetarianbull No nicotine addiction (smoking)bull Have HO Alcohol intake bull Have NASH at surgery-No cirrhosisbull Not likely to come back for follow up andbull Revision operation of Failed Sleeve gastrectomy GBP or MGB
MOHAK ALGORITHM
CHOICE OF PROCEDURE
One Anastomosis Gastric Bypass-Mini-Gastric Bypass (OAGBP-MGB) bull Have T2DM with HgbA1c 8 and durationgt5 yearsbull Have No GERDbull Are Non-vegetarianbull Have poor dentitionbull Most likely to return for follow up at the clinicbull No HO alcohol intakebull No Nicotine addiction (smoking)bull Normal LFTsbull No NASH at surgery or cirrhosisbull Commitment by our program to have 100 follow up of theses patient
Revision Operationbull Sleeve to Banded RY with 100 cm Al limb and 180 cm BP Limbbull MGB to diverted MGB for Reflux Existing BPL and 100cm ALbull MGB to GBP for PCM or reversal to normal anatomy for PCMmdashinterim gastrostomy feedingbull GBP to BGBP with 180cm BP limb for Weight regain or inadequate weight loss BMIlt40bull GBP to BGBP with 300cm common limb for Weight regain or inadequate weight loss BMIgt40
MOHAK ALGORITHM
CHOICE OF PROCEDURE
bull Laparoscopic Gastric Bypass
bull Laparoscopic Sleeve Gastrectomy
bull Divided Mini-Gastric Bypass
bull Biliopancreatic Diversion with DS
bull Single Anastomosis Duodeno-ileostomy
bull Gastric Plication
bull Banded Gastric Plication
bull Endoscopic Gastroplasty
bull Laparoscopic Adjustable Gastric bands
bull Balloon Implantation
bull Ileal interposition
These other operations will be used selectively based on patients needs and the surgeons determination
CHOICE OF PROCEDURE
The MOHAK Guide for Choice of Bariatric Metabolic Surgery Operations
Single Incision Laparoscopic Robotic and Endoscopic approaches are
available at patientsrsquo requests and the discretion of the surgeon
CHOICE OF PROCEDURE
The MOHAK Guide for Choice of Bariatric Metabolic Surgery Operations
Mohak Bariatrics and Robotics Surgery Center Motto
ldquoThe best operation for the patient by a competent surgeon in a well equipped hospital to maximize outcomes with the least amount of risks exposurerdquo
WE ARE ABLE TO CHOOSE THE BEST BARIATRIC METABOLIC PROCEDURE FOR YOUR PATIENT
Good long-term results are our marketing toolSuccessful patients make a lot of referralsbull
CHOICE OF PROCEDURE
The MOHAK Guide for Choice of Bariatric Metabolic Surgery Operations
We offer various treatment modalities for obesity The operation is
determined by the profile of the patient and guided by findings from
analysis of the data from our prospectively maintained database
MOHAK TEAM INDORE INDIA
THANK YOU
OAGBPMGB
One Anastamosis Gastric BypassMini Gastric Bypass (OAGBMGB)
Simplicity
Repeatability
Minimal Dissection
Reversibility
Exit Strategy
Safety
Minimal Suturing
Short Duration
Short Learning Curve
CHOICE OF PROCEDURE
OAGBSAGBMGB Advantagesbull Easier operation compared to Standard GBPbull Better food tolerancebull More weight loss than standard GBPbull Better weigh Loss Maintenancebull Higher metabolic effect on T2DM and Hyperlipidemiabull Less incidence of internal herniabull More options for revision if needed
Disadvantagesbull Bile reflux gastritis and esophagitisbull Marginal ulcersbull Nutrient deficienciesbull Protein Caloric Malnutrition
Quan Y Huanh A Ye M Efficacy of laproscopic mini gastric bypass for obesity and type 2 diabetes mellitus A systematic review and met-analysis Gastroenterol Res Pract 2015 ID 152852 10155
CHOICE OF PROCEDURE
2015 ndash Review articleVictorzon M et al Scand J Surg 2015 Mar104(1)48-53 Single-anastomosis gastric
bypass better faster and safer
bull The abstracts of 73 articles were reviewed and after removal of case studies duplicates and irrelevant articles 10 articles remained for closer review
bull Several thousand of this operation have been performed for more than 15 years It is claimed to be an easier safer faster and more effective metabolic operation compared to the standard Roux-en-Y gastric bypass The proponents of this operation also claim that this operation is easier to revise and reverse leaving more options compared to the situation after standard bypass in case of failure However there is much controversy surrounding this method mainly concerning the possible harmful and in the long-term even carcinogenic effects of biliopancreaticoduodenal reflux in the gastric pouch
Comment
Several thousands MGBs performed over 15 yrsEasier safer faster amp more effective than
RYGBEasier to revise amp reverse
Controversy regarding carcinogenic effect of BPD reflux
1306
1213
1294
1218
131
1207
114
116
118
12
122
124
126
128
13
132
Before After
BGB LGB MGB
Hemoglobin
RYGB VS Banded RYGB VS OAGBMGB
CHOICE OF PROCEDURE
399
372
394
36
396
352
32
33
34
35
36
37
38
39
4
41
Before After
BGB LGB MGB
Albumin661
644
693
67
685
607
56
58
6
62
64
66
68
7
Before After
BGB LGB MGB
Protein
RYGB VS Banded RYGB VS OAGBMGB
CHOICE OF PROCEDURE
911
87
906
873
909
833
78
8
82
84
86
88
9
92
Before After
BGB LGB MGB
Calcium
CHOICE OF PROCEDURE
RYGB VS Banded RYGB VS OAGBMGB
COMPARISON OF BGBP OAGB VS STD GBP
Outcome after the operations BGBP OAGBP STD GBP
Av Initial weight loss 1-3yrs gt77 gt77 65-70
Weight loss 4-10 years 70-77 70-77 55-65
Resolution of T2DM 80--85 80-90 60-80
VomitingSolid Food Intolerance 5-15 lt5 lt5
Diarrhea and Steatorrhea 1-2A 15-30 NA
Symptomatic Reflux 1-3 3-11 1-3
Marginal Ulcers 3-5 3-5 3-5
Protein Caloric Malnutrition lt1 3-11 lt1
Significant Weight regain 3-10 3-10 10-35
Ringband Erosion 0-1 NA NA
CHOICE OF PROCEDURE
We have enough information currently to enhance the outcome and minimize the risk by matching the operation to the patient
That is the basis forAn Algorithm for Bariatric Metabolic Operations
CHOOSING THE BEST BARIATRIC METABOLIC PROCEDURE FOR THE PATIENT
CHOICE OF PROCEDURE
bull All agesbull With no diabetesbull With low BMI preferably lt40bull With no GERDbull With HO PUDbull With HO or findings of liver diseasebull With Inflammatory bowel diseasebull With dense adhesions from multiple small bowel surgeriesbull Without HO VTEbull In heavy smokers who are not likely to quitbull In gastric cancer endemic areasbull High Risk needing minimal anesthesia and OR timebull High BMI gt 60 as part of a two stage approach
ALGORITHM
LSG BSG
CHOICE OF PROCEDURE
Laparoscopic Sleeve Gastrectomy Or Banded Sleeve Gastrostomy (SGBSD) Indicated for Patients
-All ages-Patients with T2DM lt5years and HbA1-c lt8 C-Peptidegt2 and not on insulin
-Patients with GERD
-ALL BMI ----- -BGBPBMIlt50-- LGBP
Vegetarian (BGBP)
BGBPLGBP
CHOICE OF PROCEDURE
ALGORITHM
Laparoscopic Gastric Bypass(LGBP) or Banded Gastric Bypass(BGBP) Indicated for Patients
bull With Diabetes gt5 years HbA1cgt8 C-Peptide lt2andor on Insulinbull All agesbull All BMI particularly High BMI-gt50bull High risk patients with need for short anesthesia timebull Because it is an easy to perform procedurebull Best tolerated by non Vegetarian
bull GERD Is a contraindicationbull Liver disease is a contraindication
Must be able to follow up patient regularlyPatient must be able to afford the required supplements OAGB
CHOICE OF PROCEDURE
ALGORITHM
OAGBMGB for patients
Sleeve gastrectomy with duodenal bypass(SGDJB) in patients with indication for Gastric Bypass in Gastric Cancer Endemic Areas
As effective as GBPSame weight loss andmetabolic effects as gastric bypass
SG-DJB
CHOICE OF PROCEDURE
ALGORITHM
Sleeve gastrectomy with duodenal bypass(SGDJB) in patients
1Second stage operation for the sleeve gastrectomy
2 Non responders or complications of sleeve gastric bypass or OAGBMGB
BPD-DS SADI SASI SG with enteral bypass
CHOICE OF PROCEDURE
ALGORITHM
BPD-DS SADI SAGI SASI) Indicated for
Areas with high incidence of anemia and very strict vegetarian food habits
CHOICE OF PROCEDURE
ALGORITHM
Sleeve Gastrectomy with gastro-jejunal gastro-ileal or entero-enteral anastomosis
Intra Gastric Balloon ENDOBARRIER
V-BLOC Aspire AssistEndoscopic Plication
For a patient who does not want an intra abdominal gastro-intestinal procedure
CHOICE OF PROCEDURE
Should You Do A Bariatric Metabolic Operation Because That Is What The Patient Wantsrdquo
NOYESmdashIt depends HoweverA bariatric metabolic surgeon should be able to offer the best operation for the patient based on the patientrsquos profile It is good practice to refer the patient to a tertiary center if the surgeon does not offer the operation that meets the patients indication
CHOICE OF PROCEDURE
CHOOSING THE BEST BARIATRIC METABOLIC PROCEDURE FOR THE PATIENT
CHOICE OF PROCEDURE
Case 157 yo Male BMI 57KgM2 T2DM GERD Strict Vegetarian
Algorithm
Gastric bypass-----Preferably Banded gastric bypassmdash------GERD Vegetarian
Not Sleeve because of T2DM GERD and High BMI
Not OAGBMGB because of GERD and probable of protein deficiency
CHOOSING THE BEST BARIATRIC METABOLIC PROCEDURE FOR THE PATIENT
CHOICE OF PROCEDURE
Case 1128 y0 F BMI 42 PCO DUB OSA and HO Migraine headaches
AlgorithmSleeve GastrectomymdashPreferably a Ring banded Sleeve gastrectomy
----No T2DM---No GERDNot Gastric bypass mdash anemia smelly flatus
Not OAGBMGB----Anemia Foul smelling flatus and body odor----Protein deficiency
CHOOSING THE BEST BARIATRIC METABOLIC PROCEDURE FOR THE PATIENT
CHOICE OF PROCEDURE
Case 11137 yo Male BMI 68 OSA OA and a non vegetarian who works at your hospitalReferred by the pulmonologist at your medical Centre
Algorithm
OAGBMGBmdashHigh BMI Non Veg-better food tolerance patient very likely to be followedand to afford the supplements because of proximity to your center
Not sleeve---poor weight loss with sleeve in super obeseNot Banded sleeve---Good weight loss but poor food tolerance since patient is a non vegetarianNot Gastric bypass---Weight loss in super obese have high non response after gastric bypass
and the gastric bypass is technically a more difficult operation than the OAGBNot Banded gastric bypass ndashGood weight loss but a BGBP is a more difficult operation and
the patient will have some food intolerance because of the ring
SURGICAL TREATMENT OPTIONS
At Mohak we perform these standard three operations and their banded modifications
Sleeve Gastrectomy Gastric Bypass OAGBMGB
CHOICE OF PROCEDURE
Evidence based operations performed at MBRSC From 2010 t0 2017---Standardized OperationsLaparoscopic Sleeve Gastrectomybull 90-120 cc Sleevebull 2-5cm from pylorusbull Where a sleeve is indicated but a band is contraindicated or not affordableBanded Sleeve Gastrectomy (BSG) 84 EWL after 60 monthsbull 90-120 cc Sleevebull 2-5cm from pylorusbull Ring 65-75 cmbull At 3-6 cm below GE junctionBanded Gastric bypass (BGBP) 75 EWL 48 monthsbull Create 6mdash7cm long pouchbull 65-75 cm ring at 3-5 cm below GE junction and gt2cm above anastomosisbull Large Gastroenterostomy gt 2cm bull 100cm Roux Limb and 80 cm BP limb for BMIlt50bull 100cm Roux Limb and 150 cm BP limb for BMIgt50Mini-Gastric Bypass (MGB) (OAGB) 79 EWL 60 monthsbull 9-18cm long pouch ~25cm widebull BP Limb length of 180cm BMIlt50Banded Mini-Gastric Bypass(BMGB)(BOAGB)bull 9-18cm long pouch ~25cm widebull Ring 7-75 cmbull BP Limb length of 180cm BMI50
THE MOHAK PROTOCOLStandardized Bariatric and Robotic Surgery Operations
CHOICE OF PROCEDURE
Sleeve Gastrectomy (LSG) or Banded Sleeve Gastrectomy (BSG)bull Non-diabeticsbull No hiatal hernia or GERDbull HO Smokingbull HO alcohol usebull HO PUDbull Abnormal LFTs NASH and early Cirrhosisbull Pts from areas with high incidence of gastric cancer of H pylori infectionbull High risks patients and super obese patients as part of a two-staged operation
Gastric Bypass (LGBP) or Banded Gastric Bypass (BGBP) or Hybrid BGBPMGBbull Have T2DM with HgbA1c lt 8 and duration lt 5 yearsbull Have Hiatal hernia or GERDbull Are Vegetarianbull No nicotine addiction (smoking)bull Have HO Alcohol intake bull Have NASH at surgery-No cirrhosisbull Not likely to come back for follow up andbull Revision operation of Failed Sleeve gastrectomy GBP or MGB
MOHAK ALGORITHM
CHOICE OF PROCEDURE
One Anastomosis Gastric Bypass-Mini-Gastric Bypass (OAGBP-MGB) bull Have T2DM with HgbA1c 8 and durationgt5 yearsbull Have No GERDbull Are Non-vegetarianbull Have poor dentitionbull Most likely to return for follow up at the clinicbull No HO alcohol intakebull No Nicotine addiction (smoking)bull Normal LFTsbull No NASH at surgery or cirrhosisbull Commitment by our program to have 100 follow up of theses patient
Revision Operationbull Sleeve to Banded RY with 100 cm Al limb and 180 cm BP Limbbull MGB to diverted MGB for Reflux Existing BPL and 100cm ALbull MGB to GBP for PCM or reversal to normal anatomy for PCMmdashinterim gastrostomy feedingbull GBP to BGBP with 180cm BP limb for Weight regain or inadequate weight loss BMIlt40bull GBP to BGBP with 300cm common limb for Weight regain or inadequate weight loss BMIgt40
MOHAK ALGORITHM
CHOICE OF PROCEDURE
bull Laparoscopic Gastric Bypass
bull Laparoscopic Sleeve Gastrectomy
bull Divided Mini-Gastric Bypass
bull Biliopancreatic Diversion with DS
bull Single Anastomosis Duodeno-ileostomy
bull Gastric Plication
bull Banded Gastric Plication
bull Endoscopic Gastroplasty
bull Laparoscopic Adjustable Gastric bands
bull Balloon Implantation
bull Ileal interposition
These other operations will be used selectively based on patients needs and the surgeons determination
CHOICE OF PROCEDURE
The MOHAK Guide for Choice of Bariatric Metabolic Surgery Operations
Single Incision Laparoscopic Robotic and Endoscopic approaches are
available at patientsrsquo requests and the discretion of the surgeon
CHOICE OF PROCEDURE
The MOHAK Guide for Choice of Bariatric Metabolic Surgery Operations
Mohak Bariatrics and Robotics Surgery Center Motto
ldquoThe best operation for the patient by a competent surgeon in a well equipped hospital to maximize outcomes with the least amount of risks exposurerdquo
WE ARE ABLE TO CHOOSE THE BEST BARIATRIC METABOLIC PROCEDURE FOR YOUR PATIENT
Good long-term results are our marketing toolSuccessful patients make a lot of referralsbull
CHOICE OF PROCEDURE
The MOHAK Guide for Choice of Bariatric Metabolic Surgery Operations
We offer various treatment modalities for obesity The operation is
determined by the profile of the patient and guided by findings from
analysis of the data from our prospectively maintained database
MOHAK TEAM INDORE INDIA
THANK YOU
OAGBSAGBMGB Advantagesbull Easier operation compared to Standard GBPbull Better food tolerancebull More weight loss than standard GBPbull Better weigh Loss Maintenancebull Higher metabolic effect on T2DM and Hyperlipidemiabull Less incidence of internal herniabull More options for revision if needed
Disadvantagesbull Bile reflux gastritis and esophagitisbull Marginal ulcersbull Nutrient deficienciesbull Protein Caloric Malnutrition
Quan Y Huanh A Ye M Efficacy of laproscopic mini gastric bypass for obesity and type 2 diabetes mellitus A systematic review and met-analysis Gastroenterol Res Pract 2015 ID 152852 10155
CHOICE OF PROCEDURE
2015 ndash Review articleVictorzon M et al Scand J Surg 2015 Mar104(1)48-53 Single-anastomosis gastric
bypass better faster and safer
bull The abstracts of 73 articles were reviewed and after removal of case studies duplicates and irrelevant articles 10 articles remained for closer review
bull Several thousand of this operation have been performed for more than 15 years It is claimed to be an easier safer faster and more effective metabolic operation compared to the standard Roux-en-Y gastric bypass The proponents of this operation also claim that this operation is easier to revise and reverse leaving more options compared to the situation after standard bypass in case of failure However there is much controversy surrounding this method mainly concerning the possible harmful and in the long-term even carcinogenic effects of biliopancreaticoduodenal reflux in the gastric pouch
Comment
Several thousands MGBs performed over 15 yrsEasier safer faster amp more effective than
RYGBEasier to revise amp reverse
Controversy regarding carcinogenic effect of BPD reflux
1306
1213
1294
1218
131
1207
114
116
118
12
122
124
126
128
13
132
Before After
BGB LGB MGB
Hemoglobin
RYGB VS Banded RYGB VS OAGBMGB
CHOICE OF PROCEDURE
399
372
394
36
396
352
32
33
34
35
36
37
38
39
4
41
Before After
BGB LGB MGB
Albumin661
644
693
67
685
607
56
58
6
62
64
66
68
7
Before After
BGB LGB MGB
Protein
RYGB VS Banded RYGB VS OAGBMGB
CHOICE OF PROCEDURE
911
87
906
873
909
833
78
8
82
84
86
88
9
92
Before After
BGB LGB MGB
Calcium
CHOICE OF PROCEDURE
RYGB VS Banded RYGB VS OAGBMGB
COMPARISON OF BGBP OAGB VS STD GBP
Outcome after the operations BGBP OAGBP STD GBP
Av Initial weight loss 1-3yrs gt77 gt77 65-70
Weight loss 4-10 years 70-77 70-77 55-65
Resolution of T2DM 80--85 80-90 60-80
VomitingSolid Food Intolerance 5-15 lt5 lt5
Diarrhea and Steatorrhea 1-2A 15-30 NA
Symptomatic Reflux 1-3 3-11 1-3
Marginal Ulcers 3-5 3-5 3-5
Protein Caloric Malnutrition lt1 3-11 lt1
Significant Weight regain 3-10 3-10 10-35
Ringband Erosion 0-1 NA NA
CHOICE OF PROCEDURE
We have enough information currently to enhance the outcome and minimize the risk by matching the operation to the patient
That is the basis forAn Algorithm for Bariatric Metabolic Operations
CHOOSING THE BEST BARIATRIC METABOLIC PROCEDURE FOR THE PATIENT
CHOICE OF PROCEDURE
bull All agesbull With no diabetesbull With low BMI preferably lt40bull With no GERDbull With HO PUDbull With HO or findings of liver diseasebull With Inflammatory bowel diseasebull With dense adhesions from multiple small bowel surgeriesbull Without HO VTEbull In heavy smokers who are not likely to quitbull In gastric cancer endemic areasbull High Risk needing minimal anesthesia and OR timebull High BMI gt 60 as part of a two stage approach
ALGORITHM
LSG BSG
CHOICE OF PROCEDURE
Laparoscopic Sleeve Gastrectomy Or Banded Sleeve Gastrostomy (SGBSD) Indicated for Patients
-All ages-Patients with T2DM lt5years and HbA1-c lt8 C-Peptidegt2 and not on insulin
-Patients with GERD
-ALL BMI ----- -BGBPBMIlt50-- LGBP
Vegetarian (BGBP)
BGBPLGBP
CHOICE OF PROCEDURE
ALGORITHM
Laparoscopic Gastric Bypass(LGBP) or Banded Gastric Bypass(BGBP) Indicated for Patients
bull With Diabetes gt5 years HbA1cgt8 C-Peptide lt2andor on Insulinbull All agesbull All BMI particularly High BMI-gt50bull High risk patients with need for short anesthesia timebull Because it is an easy to perform procedurebull Best tolerated by non Vegetarian
bull GERD Is a contraindicationbull Liver disease is a contraindication
Must be able to follow up patient regularlyPatient must be able to afford the required supplements OAGB
CHOICE OF PROCEDURE
ALGORITHM
OAGBMGB for patients
Sleeve gastrectomy with duodenal bypass(SGDJB) in patients with indication for Gastric Bypass in Gastric Cancer Endemic Areas
As effective as GBPSame weight loss andmetabolic effects as gastric bypass
SG-DJB
CHOICE OF PROCEDURE
ALGORITHM
Sleeve gastrectomy with duodenal bypass(SGDJB) in patients
1Second stage operation for the sleeve gastrectomy
2 Non responders or complications of sleeve gastric bypass or OAGBMGB
BPD-DS SADI SASI SG with enteral bypass
CHOICE OF PROCEDURE
ALGORITHM
BPD-DS SADI SAGI SASI) Indicated for
Areas with high incidence of anemia and very strict vegetarian food habits
CHOICE OF PROCEDURE
ALGORITHM
Sleeve Gastrectomy with gastro-jejunal gastro-ileal or entero-enteral anastomosis
Intra Gastric Balloon ENDOBARRIER
V-BLOC Aspire AssistEndoscopic Plication
For a patient who does not want an intra abdominal gastro-intestinal procedure
CHOICE OF PROCEDURE
Should You Do A Bariatric Metabolic Operation Because That Is What The Patient Wantsrdquo
NOYESmdashIt depends HoweverA bariatric metabolic surgeon should be able to offer the best operation for the patient based on the patientrsquos profile It is good practice to refer the patient to a tertiary center if the surgeon does not offer the operation that meets the patients indication
CHOICE OF PROCEDURE
CHOOSING THE BEST BARIATRIC METABOLIC PROCEDURE FOR THE PATIENT
CHOICE OF PROCEDURE
Case 157 yo Male BMI 57KgM2 T2DM GERD Strict Vegetarian
Algorithm
Gastric bypass-----Preferably Banded gastric bypassmdash------GERD Vegetarian
Not Sleeve because of T2DM GERD and High BMI
Not OAGBMGB because of GERD and probable of protein deficiency
CHOOSING THE BEST BARIATRIC METABOLIC PROCEDURE FOR THE PATIENT
CHOICE OF PROCEDURE
Case 1128 y0 F BMI 42 PCO DUB OSA and HO Migraine headaches
AlgorithmSleeve GastrectomymdashPreferably a Ring banded Sleeve gastrectomy
----No T2DM---No GERDNot Gastric bypass mdash anemia smelly flatus
Not OAGBMGB----Anemia Foul smelling flatus and body odor----Protein deficiency
CHOOSING THE BEST BARIATRIC METABOLIC PROCEDURE FOR THE PATIENT
CHOICE OF PROCEDURE
Case 11137 yo Male BMI 68 OSA OA and a non vegetarian who works at your hospitalReferred by the pulmonologist at your medical Centre
Algorithm
OAGBMGBmdashHigh BMI Non Veg-better food tolerance patient very likely to be followedand to afford the supplements because of proximity to your center
Not sleeve---poor weight loss with sleeve in super obeseNot Banded sleeve---Good weight loss but poor food tolerance since patient is a non vegetarianNot Gastric bypass---Weight loss in super obese have high non response after gastric bypass
and the gastric bypass is technically a more difficult operation than the OAGBNot Banded gastric bypass ndashGood weight loss but a BGBP is a more difficult operation and
the patient will have some food intolerance because of the ring
SURGICAL TREATMENT OPTIONS
At Mohak we perform these standard three operations and their banded modifications
Sleeve Gastrectomy Gastric Bypass OAGBMGB
CHOICE OF PROCEDURE
Evidence based operations performed at MBRSC From 2010 t0 2017---Standardized OperationsLaparoscopic Sleeve Gastrectomybull 90-120 cc Sleevebull 2-5cm from pylorusbull Where a sleeve is indicated but a band is contraindicated or not affordableBanded Sleeve Gastrectomy (BSG) 84 EWL after 60 monthsbull 90-120 cc Sleevebull 2-5cm from pylorusbull Ring 65-75 cmbull At 3-6 cm below GE junctionBanded Gastric bypass (BGBP) 75 EWL 48 monthsbull Create 6mdash7cm long pouchbull 65-75 cm ring at 3-5 cm below GE junction and gt2cm above anastomosisbull Large Gastroenterostomy gt 2cm bull 100cm Roux Limb and 80 cm BP limb for BMIlt50bull 100cm Roux Limb and 150 cm BP limb for BMIgt50Mini-Gastric Bypass (MGB) (OAGB) 79 EWL 60 monthsbull 9-18cm long pouch ~25cm widebull BP Limb length of 180cm BMIlt50Banded Mini-Gastric Bypass(BMGB)(BOAGB)bull 9-18cm long pouch ~25cm widebull Ring 7-75 cmbull BP Limb length of 180cm BMI50
THE MOHAK PROTOCOLStandardized Bariatric and Robotic Surgery Operations
CHOICE OF PROCEDURE
Sleeve Gastrectomy (LSG) or Banded Sleeve Gastrectomy (BSG)bull Non-diabeticsbull No hiatal hernia or GERDbull HO Smokingbull HO alcohol usebull HO PUDbull Abnormal LFTs NASH and early Cirrhosisbull Pts from areas with high incidence of gastric cancer of H pylori infectionbull High risks patients and super obese patients as part of a two-staged operation
Gastric Bypass (LGBP) or Banded Gastric Bypass (BGBP) or Hybrid BGBPMGBbull Have T2DM with HgbA1c lt 8 and duration lt 5 yearsbull Have Hiatal hernia or GERDbull Are Vegetarianbull No nicotine addiction (smoking)bull Have HO Alcohol intake bull Have NASH at surgery-No cirrhosisbull Not likely to come back for follow up andbull Revision operation of Failed Sleeve gastrectomy GBP or MGB
MOHAK ALGORITHM
CHOICE OF PROCEDURE
One Anastomosis Gastric Bypass-Mini-Gastric Bypass (OAGBP-MGB) bull Have T2DM with HgbA1c 8 and durationgt5 yearsbull Have No GERDbull Are Non-vegetarianbull Have poor dentitionbull Most likely to return for follow up at the clinicbull No HO alcohol intakebull No Nicotine addiction (smoking)bull Normal LFTsbull No NASH at surgery or cirrhosisbull Commitment by our program to have 100 follow up of theses patient
Revision Operationbull Sleeve to Banded RY with 100 cm Al limb and 180 cm BP Limbbull MGB to diverted MGB for Reflux Existing BPL and 100cm ALbull MGB to GBP for PCM or reversal to normal anatomy for PCMmdashinterim gastrostomy feedingbull GBP to BGBP with 180cm BP limb for Weight regain or inadequate weight loss BMIlt40bull GBP to BGBP with 300cm common limb for Weight regain or inadequate weight loss BMIgt40
MOHAK ALGORITHM
CHOICE OF PROCEDURE
bull Laparoscopic Gastric Bypass
bull Laparoscopic Sleeve Gastrectomy
bull Divided Mini-Gastric Bypass
bull Biliopancreatic Diversion with DS
bull Single Anastomosis Duodeno-ileostomy
bull Gastric Plication
bull Banded Gastric Plication
bull Endoscopic Gastroplasty
bull Laparoscopic Adjustable Gastric bands
bull Balloon Implantation
bull Ileal interposition
These other operations will be used selectively based on patients needs and the surgeons determination
CHOICE OF PROCEDURE
The MOHAK Guide for Choice of Bariatric Metabolic Surgery Operations
Single Incision Laparoscopic Robotic and Endoscopic approaches are
available at patientsrsquo requests and the discretion of the surgeon
CHOICE OF PROCEDURE
The MOHAK Guide for Choice of Bariatric Metabolic Surgery Operations
Mohak Bariatrics and Robotics Surgery Center Motto
ldquoThe best operation for the patient by a competent surgeon in a well equipped hospital to maximize outcomes with the least amount of risks exposurerdquo
WE ARE ABLE TO CHOOSE THE BEST BARIATRIC METABOLIC PROCEDURE FOR YOUR PATIENT
Good long-term results are our marketing toolSuccessful patients make a lot of referralsbull
CHOICE OF PROCEDURE
The MOHAK Guide for Choice of Bariatric Metabolic Surgery Operations
We offer various treatment modalities for obesity The operation is
determined by the profile of the patient and guided by findings from
analysis of the data from our prospectively maintained database
MOHAK TEAM INDORE INDIA
THANK YOU
2015 ndash Review articleVictorzon M et al Scand J Surg 2015 Mar104(1)48-53 Single-anastomosis gastric
bypass better faster and safer
bull The abstracts of 73 articles were reviewed and after removal of case studies duplicates and irrelevant articles 10 articles remained for closer review
bull Several thousand of this operation have been performed for more than 15 years It is claimed to be an easier safer faster and more effective metabolic operation compared to the standard Roux-en-Y gastric bypass The proponents of this operation also claim that this operation is easier to revise and reverse leaving more options compared to the situation after standard bypass in case of failure However there is much controversy surrounding this method mainly concerning the possible harmful and in the long-term even carcinogenic effects of biliopancreaticoduodenal reflux in the gastric pouch
Comment
Several thousands MGBs performed over 15 yrsEasier safer faster amp more effective than
RYGBEasier to revise amp reverse
Controversy regarding carcinogenic effect of BPD reflux
1306
1213
1294
1218
131
1207
114
116
118
12
122
124
126
128
13
132
Before After
BGB LGB MGB
Hemoglobin
RYGB VS Banded RYGB VS OAGBMGB
CHOICE OF PROCEDURE
399
372
394
36
396
352
32
33
34
35
36
37
38
39
4
41
Before After
BGB LGB MGB
Albumin661
644
693
67
685
607
56
58
6
62
64
66
68
7
Before After
BGB LGB MGB
Protein
RYGB VS Banded RYGB VS OAGBMGB
CHOICE OF PROCEDURE
911
87
906
873
909
833
78
8
82
84
86
88
9
92
Before After
BGB LGB MGB
Calcium
CHOICE OF PROCEDURE
RYGB VS Banded RYGB VS OAGBMGB
COMPARISON OF BGBP OAGB VS STD GBP
Outcome after the operations BGBP OAGBP STD GBP
Av Initial weight loss 1-3yrs gt77 gt77 65-70
Weight loss 4-10 years 70-77 70-77 55-65
Resolution of T2DM 80--85 80-90 60-80
VomitingSolid Food Intolerance 5-15 lt5 lt5
Diarrhea and Steatorrhea 1-2A 15-30 NA
Symptomatic Reflux 1-3 3-11 1-3
Marginal Ulcers 3-5 3-5 3-5
Protein Caloric Malnutrition lt1 3-11 lt1
Significant Weight regain 3-10 3-10 10-35
Ringband Erosion 0-1 NA NA
CHOICE OF PROCEDURE
We have enough information currently to enhance the outcome and minimize the risk by matching the operation to the patient
That is the basis forAn Algorithm for Bariatric Metabolic Operations
CHOOSING THE BEST BARIATRIC METABOLIC PROCEDURE FOR THE PATIENT
CHOICE OF PROCEDURE
bull All agesbull With no diabetesbull With low BMI preferably lt40bull With no GERDbull With HO PUDbull With HO or findings of liver diseasebull With Inflammatory bowel diseasebull With dense adhesions from multiple small bowel surgeriesbull Without HO VTEbull In heavy smokers who are not likely to quitbull In gastric cancer endemic areasbull High Risk needing minimal anesthesia and OR timebull High BMI gt 60 as part of a two stage approach
ALGORITHM
LSG BSG
CHOICE OF PROCEDURE
Laparoscopic Sleeve Gastrectomy Or Banded Sleeve Gastrostomy (SGBSD) Indicated for Patients
-All ages-Patients with T2DM lt5years and HbA1-c lt8 C-Peptidegt2 and not on insulin
-Patients with GERD
-ALL BMI ----- -BGBPBMIlt50-- LGBP
Vegetarian (BGBP)
BGBPLGBP
CHOICE OF PROCEDURE
ALGORITHM
Laparoscopic Gastric Bypass(LGBP) or Banded Gastric Bypass(BGBP) Indicated for Patients
bull With Diabetes gt5 years HbA1cgt8 C-Peptide lt2andor on Insulinbull All agesbull All BMI particularly High BMI-gt50bull High risk patients with need for short anesthesia timebull Because it is an easy to perform procedurebull Best tolerated by non Vegetarian
bull GERD Is a contraindicationbull Liver disease is a contraindication
Must be able to follow up patient regularlyPatient must be able to afford the required supplements OAGB
CHOICE OF PROCEDURE
ALGORITHM
OAGBMGB for patients
Sleeve gastrectomy with duodenal bypass(SGDJB) in patients with indication for Gastric Bypass in Gastric Cancer Endemic Areas
As effective as GBPSame weight loss andmetabolic effects as gastric bypass
SG-DJB
CHOICE OF PROCEDURE
ALGORITHM
Sleeve gastrectomy with duodenal bypass(SGDJB) in patients
1Second stage operation for the sleeve gastrectomy
2 Non responders or complications of sleeve gastric bypass or OAGBMGB
BPD-DS SADI SASI SG with enteral bypass
CHOICE OF PROCEDURE
ALGORITHM
BPD-DS SADI SAGI SASI) Indicated for
Areas with high incidence of anemia and very strict vegetarian food habits
CHOICE OF PROCEDURE
ALGORITHM
Sleeve Gastrectomy with gastro-jejunal gastro-ileal or entero-enteral anastomosis
Intra Gastric Balloon ENDOBARRIER
V-BLOC Aspire AssistEndoscopic Plication
For a patient who does not want an intra abdominal gastro-intestinal procedure
CHOICE OF PROCEDURE
Should You Do A Bariatric Metabolic Operation Because That Is What The Patient Wantsrdquo
NOYESmdashIt depends HoweverA bariatric metabolic surgeon should be able to offer the best operation for the patient based on the patientrsquos profile It is good practice to refer the patient to a tertiary center if the surgeon does not offer the operation that meets the patients indication
CHOICE OF PROCEDURE
CHOOSING THE BEST BARIATRIC METABOLIC PROCEDURE FOR THE PATIENT
CHOICE OF PROCEDURE
Case 157 yo Male BMI 57KgM2 T2DM GERD Strict Vegetarian
Algorithm
Gastric bypass-----Preferably Banded gastric bypassmdash------GERD Vegetarian
Not Sleeve because of T2DM GERD and High BMI
Not OAGBMGB because of GERD and probable of protein deficiency
CHOOSING THE BEST BARIATRIC METABOLIC PROCEDURE FOR THE PATIENT
CHOICE OF PROCEDURE
Case 1128 y0 F BMI 42 PCO DUB OSA and HO Migraine headaches
AlgorithmSleeve GastrectomymdashPreferably a Ring banded Sleeve gastrectomy
----No T2DM---No GERDNot Gastric bypass mdash anemia smelly flatus
Not OAGBMGB----Anemia Foul smelling flatus and body odor----Protein deficiency
CHOOSING THE BEST BARIATRIC METABOLIC PROCEDURE FOR THE PATIENT
CHOICE OF PROCEDURE
Case 11137 yo Male BMI 68 OSA OA and a non vegetarian who works at your hospitalReferred by the pulmonologist at your medical Centre
Algorithm
OAGBMGBmdashHigh BMI Non Veg-better food tolerance patient very likely to be followedand to afford the supplements because of proximity to your center
Not sleeve---poor weight loss with sleeve in super obeseNot Banded sleeve---Good weight loss but poor food tolerance since patient is a non vegetarianNot Gastric bypass---Weight loss in super obese have high non response after gastric bypass
and the gastric bypass is technically a more difficult operation than the OAGBNot Banded gastric bypass ndashGood weight loss but a BGBP is a more difficult operation and
the patient will have some food intolerance because of the ring
SURGICAL TREATMENT OPTIONS
At Mohak we perform these standard three operations and their banded modifications
Sleeve Gastrectomy Gastric Bypass OAGBMGB
CHOICE OF PROCEDURE
Evidence based operations performed at MBRSC From 2010 t0 2017---Standardized OperationsLaparoscopic Sleeve Gastrectomybull 90-120 cc Sleevebull 2-5cm from pylorusbull Where a sleeve is indicated but a band is contraindicated or not affordableBanded Sleeve Gastrectomy (BSG) 84 EWL after 60 monthsbull 90-120 cc Sleevebull 2-5cm from pylorusbull Ring 65-75 cmbull At 3-6 cm below GE junctionBanded Gastric bypass (BGBP) 75 EWL 48 monthsbull Create 6mdash7cm long pouchbull 65-75 cm ring at 3-5 cm below GE junction and gt2cm above anastomosisbull Large Gastroenterostomy gt 2cm bull 100cm Roux Limb and 80 cm BP limb for BMIlt50bull 100cm Roux Limb and 150 cm BP limb for BMIgt50Mini-Gastric Bypass (MGB) (OAGB) 79 EWL 60 monthsbull 9-18cm long pouch ~25cm widebull BP Limb length of 180cm BMIlt50Banded Mini-Gastric Bypass(BMGB)(BOAGB)bull 9-18cm long pouch ~25cm widebull Ring 7-75 cmbull BP Limb length of 180cm BMI50
THE MOHAK PROTOCOLStandardized Bariatric and Robotic Surgery Operations
CHOICE OF PROCEDURE
Sleeve Gastrectomy (LSG) or Banded Sleeve Gastrectomy (BSG)bull Non-diabeticsbull No hiatal hernia or GERDbull HO Smokingbull HO alcohol usebull HO PUDbull Abnormal LFTs NASH and early Cirrhosisbull Pts from areas with high incidence of gastric cancer of H pylori infectionbull High risks patients and super obese patients as part of a two-staged operation
Gastric Bypass (LGBP) or Banded Gastric Bypass (BGBP) or Hybrid BGBPMGBbull Have T2DM with HgbA1c lt 8 and duration lt 5 yearsbull Have Hiatal hernia or GERDbull Are Vegetarianbull No nicotine addiction (smoking)bull Have HO Alcohol intake bull Have NASH at surgery-No cirrhosisbull Not likely to come back for follow up andbull Revision operation of Failed Sleeve gastrectomy GBP or MGB
MOHAK ALGORITHM
CHOICE OF PROCEDURE
One Anastomosis Gastric Bypass-Mini-Gastric Bypass (OAGBP-MGB) bull Have T2DM with HgbA1c 8 and durationgt5 yearsbull Have No GERDbull Are Non-vegetarianbull Have poor dentitionbull Most likely to return for follow up at the clinicbull No HO alcohol intakebull No Nicotine addiction (smoking)bull Normal LFTsbull No NASH at surgery or cirrhosisbull Commitment by our program to have 100 follow up of theses patient
Revision Operationbull Sleeve to Banded RY with 100 cm Al limb and 180 cm BP Limbbull MGB to diverted MGB for Reflux Existing BPL and 100cm ALbull MGB to GBP for PCM or reversal to normal anatomy for PCMmdashinterim gastrostomy feedingbull GBP to BGBP with 180cm BP limb for Weight regain or inadequate weight loss BMIlt40bull GBP to BGBP with 300cm common limb for Weight regain or inadequate weight loss BMIgt40
MOHAK ALGORITHM
CHOICE OF PROCEDURE
bull Laparoscopic Gastric Bypass
bull Laparoscopic Sleeve Gastrectomy
bull Divided Mini-Gastric Bypass
bull Biliopancreatic Diversion with DS
bull Single Anastomosis Duodeno-ileostomy
bull Gastric Plication
bull Banded Gastric Plication
bull Endoscopic Gastroplasty
bull Laparoscopic Adjustable Gastric bands
bull Balloon Implantation
bull Ileal interposition
These other operations will be used selectively based on patients needs and the surgeons determination
CHOICE OF PROCEDURE
The MOHAK Guide for Choice of Bariatric Metabolic Surgery Operations
Single Incision Laparoscopic Robotic and Endoscopic approaches are
available at patientsrsquo requests and the discretion of the surgeon
CHOICE OF PROCEDURE
The MOHAK Guide for Choice of Bariatric Metabolic Surgery Operations
Mohak Bariatrics and Robotics Surgery Center Motto
ldquoThe best operation for the patient by a competent surgeon in a well equipped hospital to maximize outcomes with the least amount of risks exposurerdquo
WE ARE ABLE TO CHOOSE THE BEST BARIATRIC METABOLIC PROCEDURE FOR YOUR PATIENT
Good long-term results are our marketing toolSuccessful patients make a lot of referralsbull
CHOICE OF PROCEDURE
The MOHAK Guide for Choice of Bariatric Metabolic Surgery Operations
We offer various treatment modalities for obesity The operation is
determined by the profile of the patient and guided by findings from
analysis of the data from our prospectively maintained database
MOHAK TEAM INDORE INDIA
THANK YOU
1306
1213
1294
1218
131
1207
114
116
118
12
122
124
126
128
13
132
Before After
BGB LGB MGB
Hemoglobin
RYGB VS Banded RYGB VS OAGBMGB
CHOICE OF PROCEDURE
399
372
394
36
396
352
32
33
34
35
36
37
38
39
4
41
Before After
BGB LGB MGB
Albumin661
644
693
67
685
607
56
58
6
62
64
66
68
7
Before After
BGB LGB MGB
Protein
RYGB VS Banded RYGB VS OAGBMGB
CHOICE OF PROCEDURE
911
87
906
873
909
833
78
8
82
84
86
88
9
92
Before After
BGB LGB MGB
Calcium
CHOICE OF PROCEDURE
RYGB VS Banded RYGB VS OAGBMGB
COMPARISON OF BGBP OAGB VS STD GBP
Outcome after the operations BGBP OAGBP STD GBP
Av Initial weight loss 1-3yrs gt77 gt77 65-70
Weight loss 4-10 years 70-77 70-77 55-65
Resolution of T2DM 80--85 80-90 60-80
VomitingSolid Food Intolerance 5-15 lt5 lt5
Diarrhea and Steatorrhea 1-2A 15-30 NA
Symptomatic Reflux 1-3 3-11 1-3
Marginal Ulcers 3-5 3-5 3-5
Protein Caloric Malnutrition lt1 3-11 lt1
Significant Weight regain 3-10 3-10 10-35
Ringband Erosion 0-1 NA NA
CHOICE OF PROCEDURE
We have enough information currently to enhance the outcome and minimize the risk by matching the operation to the patient
That is the basis forAn Algorithm for Bariatric Metabolic Operations
CHOOSING THE BEST BARIATRIC METABOLIC PROCEDURE FOR THE PATIENT
CHOICE OF PROCEDURE
bull All agesbull With no diabetesbull With low BMI preferably lt40bull With no GERDbull With HO PUDbull With HO or findings of liver diseasebull With Inflammatory bowel diseasebull With dense adhesions from multiple small bowel surgeriesbull Without HO VTEbull In heavy smokers who are not likely to quitbull In gastric cancer endemic areasbull High Risk needing minimal anesthesia and OR timebull High BMI gt 60 as part of a two stage approach
ALGORITHM
LSG BSG
CHOICE OF PROCEDURE
Laparoscopic Sleeve Gastrectomy Or Banded Sleeve Gastrostomy (SGBSD) Indicated for Patients
-All ages-Patients with T2DM lt5years and HbA1-c lt8 C-Peptidegt2 and not on insulin
-Patients with GERD
-ALL BMI ----- -BGBPBMIlt50-- LGBP
Vegetarian (BGBP)
BGBPLGBP
CHOICE OF PROCEDURE
ALGORITHM
Laparoscopic Gastric Bypass(LGBP) or Banded Gastric Bypass(BGBP) Indicated for Patients
bull With Diabetes gt5 years HbA1cgt8 C-Peptide lt2andor on Insulinbull All agesbull All BMI particularly High BMI-gt50bull High risk patients with need for short anesthesia timebull Because it is an easy to perform procedurebull Best tolerated by non Vegetarian
bull GERD Is a contraindicationbull Liver disease is a contraindication
Must be able to follow up patient regularlyPatient must be able to afford the required supplements OAGB
CHOICE OF PROCEDURE
ALGORITHM
OAGBMGB for patients
Sleeve gastrectomy with duodenal bypass(SGDJB) in patients with indication for Gastric Bypass in Gastric Cancer Endemic Areas
As effective as GBPSame weight loss andmetabolic effects as gastric bypass
SG-DJB
CHOICE OF PROCEDURE
ALGORITHM
Sleeve gastrectomy with duodenal bypass(SGDJB) in patients
1Second stage operation for the sleeve gastrectomy
2 Non responders or complications of sleeve gastric bypass or OAGBMGB
BPD-DS SADI SASI SG with enteral bypass
CHOICE OF PROCEDURE
ALGORITHM
BPD-DS SADI SAGI SASI) Indicated for
Areas with high incidence of anemia and very strict vegetarian food habits
CHOICE OF PROCEDURE
ALGORITHM
Sleeve Gastrectomy with gastro-jejunal gastro-ileal or entero-enteral anastomosis
Intra Gastric Balloon ENDOBARRIER
V-BLOC Aspire AssistEndoscopic Plication
For a patient who does not want an intra abdominal gastro-intestinal procedure
CHOICE OF PROCEDURE
Should You Do A Bariatric Metabolic Operation Because That Is What The Patient Wantsrdquo
NOYESmdashIt depends HoweverA bariatric metabolic surgeon should be able to offer the best operation for the patient based on the patientrsquos profile It is good practice to refer the patient to a tertiary center if the surgeon does not offer the operation that meets the patients indication
CHOICE OF PROCEDURE
CHOOSING THE BEST BARIATRIC METABOLIC PROCEDURE FOR THE PATIENT
CHOICE OF PROCEDURE
Case 157 yo Male BMI 57KgM2 T2DM GERD Strict Vegetarian
Algorithm
Gastric bypass-----Preferably Banded gastric bypassmdash------GERD Vegetarian
Not Sleeve because of T2DM GERD and High BMI
Not OAGBMGB because of GERD and probable of protein deficiency
CHOOSING THE BEST BARIATRIC METABOLIC PROCEDURE FOR THE PATIENT
CHOICE OF PROCEDURE
Case 1128 y0 F BMI 42 PCO DUB OSA and HO Migraine headaches
AlgorithmSleeve GastrectomymdashPreferably a Ring banded Sleeve gastrectomy
----No T2DM---No GERDNot Gastric bypass mdash anemia smelly flatus
Not OAGBMGB----Anemia Foul smelling flatus and body odor----Protein deficiency
CHOOSING THE BEST BARIATRIC METABOLIC PROCEDURE FOR THE PATIENT
CHOICE OF PROCEDURE
Case 11137 yo Male BMI 68 OSA OA and a non vegetarian who works at your hospitalReferred by the pulmonologist at your medical Centre
Algorithm
OAGBMGBmdashHigh BMI Non Veg-better food tolerance patient very likely to be followedand to afford the supplements because of proximity to your center
Not sleeve---poor weight loss with sleeve in super obeseNot Banded sleeve---Good weight loss but poor food tolerance since patient is a non vegetarianNot Gastric bypass---Weight loss in super obese have high non response after gastric bypass
and the gastric bypass is technically a more difficult operation than the OAGBNot Banded gastric bypass ndashGood weight loss but a BGBP is a more difficult operation and
the patient will have some food intolerance because of the ring
SURGICAL TREATMENT OPTIONS
At Mohak we perform these standard three operations and their banded modifications
Sleeve Gastrectomy Gastric Bypass OAGBMGB
CHOICE OF PROCEDURE
Evidence based operations performed at MBRSC From 2010 t0 2017---Standardized OperationsLaparoscopic Sleeve Gastrectomybull 90-120 cc Sleevebull 2-5cm from pylorusbull Where a sleeve is indicated but a band is contraindicated or not affordableBanded Sleeve Gastrectomy (BSG) 84 EWL after 60 monthsbull 90-120 cc Sleevebull 2-5cm from pylorusbull Ring 65-75 cmbull At 3-6 cm below GE junctionBanded Gastric bypass (BGBP) 75 EWL 48 monthsbull Create 6mdash7cm long pouchbull 65-75 cm ring at 3-5 cm below GE junction and gt2cm above anastomosisbull Large Gastroenterostomy gt 2cm bull 100cm Roux Limb and 80 cm BP limb for BMIlt50bull 100cm Roux Limb and 150 cm BP limb for BMIgt50Mini-Gastric Bypass (MGB) (OAGB) 79 EWL 60 monthsbull 9-18cm long pouch ~25cm widebull BP Limb length of 180cm BMIlt50Banded Mini-Gastric Bypass(BMGB)(BOAGB)bull 9-18cm long pouch ~25cm widebull Ring 7-75 cmbull BP Limb length of 180cm BMI50
THE MOHAK PROTOCOLStandardized Bariatric and Robotic Surgery Operations
CHOICE OF PROCEDURE
Sleeve Gastrectomy (LSG) or Banded Sleeve Gastrectomy (BSG)bull Non-diabeticsbull No hiatal hernia or GERDbull HO Smokingbull HO alcohol usebull HO PUDbull Abnormal LFTs NASH and early Cirrhosisbull Pts from areas with high incidence of gastric cancer of H pylori infectionbull High risks patients and super obese patients as part of a two-staged operation
Gastric Bypass (LGBP) or Banded Gastric Bypass (BGBP) or Hybrid BGBPMGBbull Have T2DM with HgbA1c lt 8 and duration lt 5 yearsbull Have Hiatal hernia or GERDbull Are Vegetarianbull No nicotine addiction (smoking)bull Have HO Alcohol intake bull Have NASH at surgery-No cirrhosisbull Not likely to come back for follow up andbull Revision operation of Failed Sleeve gastrectomy GBP or MGB
MOHAK ALGORITHM
CHOICE OF PROCEDURE
One Anastomosis Gastric Bypass-Mini-Gastric Bypass (OAGBP-MGB) bull Have T2DM with HgbA1c 8 and durationgt5 yearsbull Have No GERDbull Are Non-vegetarianbull Have poor dentitionbull Most likely to return for follow up at the clinicbull No HO alcohol intakebull No Nicotine addiction (smoking)bull Normal LFTsbull No NASH at surgery or cirrhosisbull Commitment by our program to have 100 follow up of theses patient
Revision Operationbull Sleeve to Banded RY with 100 cm Al limb and 180 cm BP Limbbull MGB to diverted MGB for Reflux Existing BPL and 100cm ALbull MGB to GBP for PCM or reversal to normal anatomy for PCMmdashinterim gastrostomy feedingbull GBP to BGBP with 180cm BP limb for Weight regain or inadequate weight loss BMIlt40bull GBP to BGBP with 300cm common limb for Weight regain or inadequate weight loss BMIgt40
MOHAK ALGORITHM
CHOICE OF PROCEDURE
bull Laparoscopic Gastric Bypass
bull Laparoscopic Sleeve Gastrectomy
bull Divided Mini-Gastric Bypass
bull Biliopancreatic Diversion with DS
bull Single Anastomosis Duodeno-ileostomy
bull Gastric Plication
bull Banded Gastric Plication
bull Endoscopic Gastroplasty
bull Laparoscopic Adjustable Gastric bands
bull Balloon Implantation
bull Ileal interposition
These other operations will be used selectively based on patients needs and the surgeons determination
CHOICE OF PROCEDURE
The MOHAK Guide for Choice of Bariatric Metabolic Surgery Operations
Single Incision Laparoscopic Robotic and Endoscopic approaches are
available at patientsrsquo requests and the discretion of the surgeon
CHOICE OF PROCEDURE
The MOHAK Guide for Choice of Bariatric Metabolic Surgery Operations
Mohak Bariatrics and Robotics Surgery Center Motto
ldquoThe best operation for the patient by a competent surgeon in a well equipped hospital to maximize outcomes with the least amount of risks exposurerdquo
WE ARE ABLE TO CHOOSE THE BEST BARIATRIC METABOLIC PROCEDURE FOR YOUR PATIENT
Good long-term results are our marketing toolSuccessful patients make a lot of referralsbull
CHOICE OF PROCEDURE
The MOHAK Guide for Choice of Bariatric Metabolic Surgery Operations
We offer various treatment modalities for obesity The operation is
determined by the profile of the patient and guided by findings from
analysis of the data from our prospectively maintained database
MOHAK TEAM INDORE INDIA
THANK YOU
399
372
394
36
396
352
32
33
34
35
36
37
38
39
4
41
Before After
BGB LGB MGB
Albumin661
644
693
67
685
607
56
58
6
62
64
66
68
7
Before After
BGB LGB MGB
Protein
RYGB VS Banded RYGB VS OAGBMGB
CHOICE OF PROCEDURE
911
87
906
873
909
833
78
8
82
84
86
88
9
92
Before After
BGB LGB MGB
Calcium
CHOICE OF PROCEDURE
RYGB VS Banded RYGB VS OAGBMGB
COMPARISON OF BGBP OAGB VS STD GBP
Outcome after the operations BGBP OAGBP STD GBP
Av Initial weight loss 1-3yrs gt77 gt77 65-70
Weight loss 4-10 years 70-77 70-77 55-65
Resolution of T2DM 80--85 80-90 60-80
VomitingSolid Food Intolerance 5-15 lt5 lt5
Diarrhea and Steatorrhea 1-2A 15-30 NA
Symptomatic Reflux 1-3 3-11 1-3
Marginal Ulcers 3-5 3-5 3-5
Protein Caloric Malnutrition lt1 3-11 lt1
Significant Weight regain 3-10 3-10 10-35
Ringband Erosion 0-1 NA NA
CHOICE OF PROCEDURE
We have enough information currently to enhance the outcome and minimize the risk by matching the operation to the patient
That is the basis forAn Algorithm for Bariatric Metabolic Operations
CHOOSING THE BEST BARIATRIC METABOLIC PROCEDURE FOR THE PATIENT
CHOICE OF PROCEDURE
bull All agesbull With no diabetesbull With low BMI preferably lt40bull With no GERDbull With HO PUDbull With HO or findings of liver diseasebull With Inflammatory bowel diseasebull With dense adhesions from multiple small bowel surgeriesbull Without HO VTEbull In heavy smokers who are not likely to quitbull In gastric cancer endemic areasbull High Risk needing minimal anesthesia and OR timebull High BMI gt 60 as part of a two stage approach
ALGORITHM
LSG BSG
CHOICE OF PROCEDURE
Laparoscopic Sleeve Gastrectomy Or Banded Sleeve Gastrostomy (SGBSD) Indicated for Patients
-All ages-Patients with T2DM lt5years and HbA1-c lt8 C-Peptidegt2 and not on insulin
-Patients with GERD
-ALL BMI ----- -BGBPBMIlt50-- LGBP
Vegetarian (BGBP)
BGBPLGBP
CHOICE OF PROCEDURE
ALGORITHM
Laparoscopic Gastric Bypass(LGBP) or Banded Gastric Bypass(BGBP) Indicated for Patients
bull With Diabetes gt5 years HbA1cgt8 C-Peptide lt2andor on Insulinbull All agesbull All BMI particularly High BMI-gt50bull High risk patients with need for short anesthesia timebull Because it is an easy to perform procedurebull Best tolerated by non Vegetarian
bull GERD Is a contraindicationbull Liver disease is a contraindication
Must be able to follow up patient regularlyPatient must be able to afford the required supplements OAGB
CHOICE OF PROCEDURE
ALGORITHM
OAGBMGB for patients
Sleeve gastrectomy with duodenal bypass(SGDJB) in patients with indication for Gastric Bypass in Gastric Cancer Endemic Areas
As effective as GBPSame weight loss andmetabolic effects as gastric bypass
SG-DJB
CHOICE OF PROCEDURE
ALGORITHM
Sleeve gastrectomy with duodenal bypass(SGDJB) in patients
1Second stage operation for the sleeve gastrectomy
2 Non responders or complications of sleeve gastric bypass or OAGBMGB
BPD-DS SADI SASI SG with enteral bypass
CHOICE OF PROCEDURE
ALGORITHM
BPD-DS SADI SAGI SASI) Indicated for
Areas with high incidence of anemia and very strict vegetarian food habits
CHOICE OF PROCEDURE
ALGORITHM
Sleeve Gastrectomy with gastro-jejunal gastro-ileal or entero-enteral anastomosis
Intra Gastric Balloon ENDOBARRIER
V-BLOC Aspire AssistEndoscopic Plication
For a patient who does not want an intra abdominal gastro-intestinal procedure
CHOICE OF PROCEDURE
Should You Do A Bariatric Metabolic Operation Because That Is What The Patient Wantsrdquo
NOYESmdashIt depends HoweverA bariatric metabolic surgeon should be able to offer the best operation for the patient based on the patientrsquos profile It is good practice to refer the patient to a tertiary center if the surgeon does not offer the operation that meets the patients indication
CHOICE OF PROCEDURE
CHOOSING THE BEST BARIATRIC METABOLIC PROCEDURE FOR THE PATIENT
CHOICE OF PROCEDURE
Case 157 yo Male BMI 57KgM2 T2DM GERD Strict Vegetarian
Algorithm
Gastric bypass-----Preferably Banded gastric bypassmdash------GERD Vegetarian
Not Sleeve because of T2DM GERD and High BMI
Not OAGBMGB because of GERD and probable of protein deficiency
CHOOSING THE BEST BARIATRIC METABOLIC PROCEDURE FOR THE PATIENT
CHOICE OF PROCEDURE
Case 1128 y0 F BMI 42 PCO DUB OSA and HO Migraine headaches
AlgorithmSleeve GastrectomymdashPreferably a Ring banded Sleeve gastrectomy
----No T2DM---No GERDNot Gastric bypass mdash anemia smelly flatus
Not OAGBMGB----Anemia Foul smelling flatus and body odor----Protein deficiency
CHOOSING THE BEST BARIATRIC METABOLIC PROCEDURE FOR THE PATIENT
CHOICE OF PROCEDURE
Case 11137 yo Male BMI 68 OSA OA and a non vegetarian who works at your hospitalReferred by the pulmonologist at your medical Centre
Algorithm
OAGBMGBmdashHigh BMI Non Veg-better food tolerance patient very likely to be followedand to afford the supplements because of proximity to your center
Not sleeve---poor weight loss with sleeve in super obeseNot Banded sleeve---Good weight loss but poor food tolerance since patient is a non vegetarianNot Gastric bypass---Weight loss in super obese have high non response after gastric bypass
and the gastric bypass is technically a more difficult operation than the OAGBNot Banded gastric bypass ndashGood weight loss but a BGBP is a more difficult operation and
the patient will have some food intolerance because of the ring
SURGICAL TREATMENT OPTIONS
At Mohak we perform these standard three operations and their banded modifications
Sleeve Gastrectomy Gastric Bypass OAGBMGB
CHOICE OF PROCEDURE
Evidence based operations performed at MBRSC From 2010 t0 2017---Standardized OperationsLaparoscopic Sleeve Gastrectomybull 90-120 cc Sleevebull 2-5cm from pylorusbull Where a sleeve is indicated but a band is contraindicated or not affordableBanded Sleeve Gastrectomy (BSG) 84 EWL after 60 monthsbull 90-120 cc Sleevebull 2-5cm from pylorusbull Ring 65-75 cmbull At 3-6 cm below GE junctionBanded Gastric bypass (BGBP) 75 EWL 48 monthsbull Create 6mdash7cm long pouchbull 65-75 cm ring at 3-5 cm below GE junction and gt2cm above anastomosisbull Large Gastroenterostomy gt 2cm bull 100cm Roux Limb and 80 cm BP limb for BMIlt50bull 100cm Roux Limb and 150 cm BP limb for BMIgt50Mini-Gastric Bypass (MGB) (OAGB) 79 EWL 60 monthsbull 9-18cm long pouch ~25cm widebull BP Limb length of 180cm BMIlt50Banded Mini-Gastric Bypass(BMGB)(BOAGB)bull 9-18cm long pouch ~25cm widebull Ring 7-75 cmbull BP Limb length of 180cm BMI50
THE MOHAK PROTOCOLStandardized Bariatric and Robotic Surgery Operations
CHOICE OF PROCEDURE
Sleeve Gastrectomy (LSG) or Banded Sleeve Gastrectomy (BSG)bull Non-diabeticsbull No hiatal hernia or GERDbull HO Smokingbull HO alcohol usebull HO PUDbull Abnormal LFTs NASH and early Cirrhosisbull Pts from areas with high incidence of gastric cancer of H pylori infectionbull High risks patients and super obese patients as part of a two-staged operation
Gastric Bypass (LGBP) or Banded Gastric Bypass (BGBP) or Hybrid BGBPMGBbull Have T2DM with HgbA1c lt 8 and duration lt 5 yearsbull Have Hiatal hernia or GERDbull Are Vegetarianbull No nicotine addiction (smoking)bull Have HO Alcohol intake bull Have NASH at surgery-No cirrhosisbull Not likely to come back for follow up andbull Revision operation of Failed Sleeve gastrectomy GBP or MGB
MOHAK ALGORITHM
CHOICE OF PROCEDURE
One Anastomosis Gastric Bypass-Mini-Gastric Bypass (OAGBP-MGB) bull Have T2DM with HgbA1c 8 and durationgt5 yearsbull Have No GERDbull Are Non-vegetarianbull Have poor dentitionbull Most likely to return for follow up at the clinicbull No HO alcohol intakebull No Nicotine addiction (smoking)bull Normal LFTsbull No NASH at surgery or cirrhosisbull Commitment by our program to have 100 follow up of theses patient
Revision Operationbull Sleeve to Banded RY with 100 cm Al limb and 180 cm BP Limbbull MGB to diverted MGB for Reflux Existing BPL and 100cm ALbull MGB to GBP for PCM or reversal to normal anatomy for PCMmdashinterim gastrostomy feedingbull GBP to BGBP with 180cm BP limb for Weight regain or inadequate weight loss BMIlt40bull GBP to BGBP with 300cm common limb for Weight regain or inadequate weight loss BMIgt40
MOHAK ALGORITHM
CHOICE OF PROCEDURE
bull Laparoscopic Gastric Bypass
bull Laparoscopic Sleeve Gastrectomy
bull Divided Mini-Gastric Bypass
bull Biliopancreatic Diversion with DS
bull Single Anastomosis Duodeno-ileostomy
bull Gastric Plication
bull Banded Gastric Plication
bull Endoscopic Gastroplasty
bull Laparoscopic Adjustable Gastric bands
bull Balloon Implantation
bull Ileal interposition
These other operations will be used selectively based on patients needs and the surgeons determination
CHOICE OF PROCEDURE
The MOHAK Guide for Choice of Bariatric Metabolic Surgery Operations
Single Incision Laparoscopic Robotic and Endoscopic approaches are
available at patientsrsquo requests and the discretion of the surgeon
CHOICE OF PROCEDURE
The MOHAK Guide for Choice of Bariatric Metabolic Surgery Operations
Mohak Bariatrics and Robotics Surgery Center Motto
ldquoThe best operation for the patient by a competent surgeon in a well equipped hospital to maximize outcomes with the least amount of risks exposurerdquo
WE ARE ABLE TO CHOOSE THE BEST BARIATRIC METABOLIC PROCEDURE FOR YOUR PATIENT
Good long-term results are our marketing toolSuccessful patients make a lot of referralsbull
CHOICE OF PROCEDURE
The MOHAK Guide for Choice of Bariatric Metabolic Surgery Operations
We offer various treatment modalities for obesity The operation is
determined by the profile of the patient and guided by findings from
analysis of the data from our prospectively maintained database
MOHAK TEAM INDORE INDIA
THANK YOU
911
87
906
873
909
833
78
8
82
84
86
88
9
92
Before After
BGB LGB MGB
Calcium
CHOICE OF PROCEDURE
RYGB VS Banded RYGB VS OAGBMGB
COMPARISON OF BGBP OAGB VS STD GBP
Outcome after the operations BGBP OAGBP STD GBP
Av Initial weight loss 1-3yrs gt77 gt77 65-70
Weight loss 4-10 years 70-77 70-77 55-65
Resolution of T2DM 80--85 80-90 60-80
VomitingSolid Food Intolerance 5-15 lt5 lt5
Diarrhea and Steatorrhea 1-2A 15-30 NA
Symptomatic Reflux 1-3 3-11 1-3
Marginal Ulcers 3-5 3-5 3-5
Protein Caloric Malnutrition lt1 3-11 lt1
Significant Weight regain 3-10 3-10 10-35
Ringband Erosion 0-1 NA NA
CHOICE OF PROCEDURE
We have enough information currently to enhance the outcome and minimize the risk by matching the operation to the patient
That is the basis forAn Algorithm for Bariatric Metabolic Operations
CHOOSING THE BEST BARIATRIC METABOLIC PROCEDURE FOR THE PATIENT
CHOICE OF PROCEDURE
bull All agesbull With no diabetesbull With low BMI preferably lt40bull With no GERDbull With HO PUDbull With HO or findings of liver diseasebull With Inflammatory bowel diseasebull With dense adhesions from multiple small bowel surgeriesbull Without HO VTEbull In heavy smokers who are not likely to quitbull In gastric cancer endemic areasbull High Risk needing minimal anesthesia and OR timebull High BMI gt 60 as part of a two stage approach
ALGORITHM
LSG BSG
CHOICE OF PROCEDURE
Laparoscopic Sleeve Gastrectomy Or Banded Sleeve Gastrostomy (SGBSD) Indicated for Patients
-All ages-Patients with T2DM lt5years and HbA1-c lt8 C-Peptidegt2 and not on insulin
-Patients with GERD
-ALL BMI ----- -BGBPBMIlt50-- LGBP
Vegetarian (BGBP)
BGBPLGBP
CHOICE OF PROCEDURE
ALGORITHM
Laparoscopic Gastric Bypass(LGBP) or Banded Gastric Bypass(BGBP) Indicated for Patients
bull With Diabetes gt5 years HbA1cgt8 C-Peptide lt2andor on Insulinbull All agesbull All BMI particularly High BMI-gt50bull High risk patients with need for short anesthesia timebull Because it is an easy to perform procedurebull Best tolerated by non Vegetarian
bull GERD Is a contraindicationbull Liver disease is a contraindication
Must be able to follow up patient regularlyPatient must be able to afford the required supplements OAGB
CHOICE OF PROCEDURE
ALGORITHM
OAGBMGB for patients
Sleeve gastrectomy with duodenal bypass(SGDJB) in patients with indication for Gastric Bypass in Gastric Cancer Endemic Areas
As effective as GBPSame weight loss andmetabolic effects as gastric bypass
SG-DJB
CHOICE OF PROCEDURE
ALGORITHM
Sleeve gastrectomy with duodenal bypass(SGDJB) in patients
1Second stage operation for the sleeve gastrectomy
2 Non responders or complications of sleeve gastric bypass or OAGBMGB
BPD-DS SADI SASI SG with enteral bypass
CHOICE OF PROCEDURE
ALGORITHM
BPD-DS SADI SAGI SASI) Indicated for
Areas with high incidence of anemia and very strict vegetarian food habits
CHOICE OF PROCEDURE
ALGORITHM
Sleeve Gastrectomy with gastro-jejunal gastro-ileal or entero-enteral anastomosis
Intra Gastric Balloon ENDOBARRIER
V-BLOC Aspire AssistEndoscopic Plication
For a patient who does not want an intra abdominal gastro-intestinal procedure
CHOICE OF PROCEDURE
Should You Do A Bariatric Metabolic Operation Because That Is What The Patient Wantsrdquo
NOYESmdashIt depends HoweverA bariatric metabolic surgeon should be able to offer the best operation for the patient based on the patientrsquos profile It is good practice to refer the patient to a tertiary center if the surgeon does not offer the operation that meets the patients indication
CHOICE OF PROCEDURE
CHOOSING THE BEST BARIATRIC METABOLIC PROCEDURE FOR THE PATIENT
CHOICE OF PROCEDURE
Case 157 yo Male BMI 57KgM2 T2DM GERD Strict Vegetarian
Algorithm
Gastric bypass-----Preferably Banded gastric bypassmdash------GERD Vegetarian
Not Sleeve because of T2DM GERD and High BMI
Not OAGBMGB because of GERD and probable of protein deficiency
CHOOSING THE BEST BARIATRIC METABOLIC PROCEDURE FOR THE PATIENT
CHOICE OF PROCEDURE
Case 1128 y0 F BMI 42 PCO DUB OSA and HO Migraine headaches
AlgorithmSleeve GastrectomymdashPreferably a Ring banded Sleeve gastrectomy
----No T2DM---No GERDNot Gastric bypass mdash anemia smelly flatus
Not OAGBMGB----Anemia Foul smelling flatus and body odor----Protein deficiency
CHOOSING THE BEST BARIATRIC METABOLIC PROCEDURE FOR THE PATIENT
CHOICE OF PROCEDURE
Case 11137 yo Male BMI 68 OSA OA and a non vegetarian who works at your hospitalReferred by the pulmonologist at your medical Centre
Algorithm
OAGBMGBmdashHigh BMI Non Veg-better food tolerance patient very likely to be followedand to afford the supplements because of proximity to your center
Not sleeve---poor weight loss with sleeve in super obeseNot Banded sleeve---Good weight loss but poor food tolerance since patient is a non vegetarianNot Gastric bypass---Weight loss in super obese have high non response after gastric bypass
and the gastric bypass is technically a more difficult operation than the OAGBNot Banded gastric bypass ndashGood weight loss but a BGBP is a more difficult operation and
the patient will have some food intolerance because of the ring
SURGICAL TREATMENT OPTIONS
At Mohak we perform these standard three operations and their banded modifications
Sleeve Gastrectomy Gastric Bypass OAGBMGB
CHOICE OF PROCEDURE
Evidence based operations performed at MBRSC From 2010 t0 2017---Standardized OperationsLaparoscopic Sleeve Gastrectomybull 90-120 cc Sleevebull 2-5cm from pylorusbull Where a sleeve is indicated but a band is contraindicated or not affordableBanded Sleeve Gastrectomy (BSG) 84 EWL after 60 monthsbull 90-120 cc Sleevebull 2-5cm from pylorusbull Ring 65-75 cmbull At 3-6 cm below GE junctionBanded Gastric bypass (BGBP) 75 EWL 48 monthsbull Create 6mdash7cm long pouchbull 65-75 cm ring at 3-5 cm below GE junction and gt2cm above anastomosisbull Large Gastroenterostomy gt 2cm bull 100cm Roux Limb and 80 cm BP limb for BMIlt50bull 100cm Roux Limb and 150 cm BP limb for BMIgt50Mini-Gastric Bypass (MGB) (OAGB) 79 EWL 60 monthsbull 9-18cm long pouch ~25cm widebull BP Limb length of 180cm BMIlt50Banded Mini-Gastric Bypass(BMGB)(BOAGB)bull 9-18cm long pouch ~25cm widebull Ring 7-75 cmbull BP Limb length of 180cm BMI50
THE MOHAK PROTOCOLStandardized Bariatric and Robotic Surgery Operations
CHOICE OF PROCEDURE
Sleeve Gastrectomy (LSG) or Banded Sleeve Gastrectomy (BSG)bull Non-diabeticsbull No hiatal hernia or GERDbull HO Smokingbull HO alcohol usebull HO PUDbull Abnormal LFTs NASH and early Cirrhosisbull Pts from areas with high incidence of gastric cancer of H pylori infectionbull High risks patients and super obese patients as part of a two-staged operation
Gastric Bypass (LGBP) or Banded Gastric Bypass (BGBP) or Hybrid BGBPMGBbull Have T2DM with HgbA1c lt 8 and duration lt 5 yearsbull Have Hiatal hernia or GERDbull Are Vegetarianbull No nicotine addiction (smoking)bull Have HO Alcohol intake bull Have NASH at surgery-No cirrhosisbull Not likely to come back for follow up andbull Revision operation of Failed Sleeve gastrectomy GBP or MGB
MOHAK ALGORITHM
CHOICE OF PROCEDURE
One Anastomosis Gastric Bypass-Mini-Gastric Bypass (OAGBP-MGB) bull Have T2DM with HgbA1c 8 and durationgt5 yearsbull Have No GERDbull Are Non-vegetarianbull Have poor dentitionbull Most likely to return for follow up at the clinicbull No HO alcohol intakebull No Nicotine addiction (smoking)bull Normal LFTsbull No NASH at surgery or cirrhosisbull Commitment by our program to have 100 follow up of theses patient
Revision Operationbull Sleeve to Banded RY with 100 cm Al limb and 180 cm BP Limbbull MGB to diverted MGB for Reflux Existing BPL and 100cm ALbull MGB to GBP for PCM or reversal to normal anatomy for PCMmdashinterim gastrostomy feedingbull GBP to BGBP with 180cm BP limb for Weight regain or inadequate weight loss BMIlt40bull GBP to BGBP with 300cm common limb for Weight regain or inadequate weight loss BMIgt40
MOHAK ALGORITHM
CHOICE OF PROCEDURE
bull Laparoscopic Gastric Bypass
bull Laparoscopic Sleeve Gastrectomy
bull Divided Mini-Gastric Bypass
bull Biliopancreatic Diversion with DS
bull Single Anastomosis Duodeno-ileostomy
bull Gastric Plication
bull Banded Gastric Plication
bull Endoscopic Gastroplasty
bull Laparoscopic Adjustable Gastric bands
bull Balloon Implantation
bull Ileal interposition
These other operations will be used selectively based on patients needs and the surgeons determination
CHOICE OF PROCEDURE
The MOHAK Guide for Choice of Bariatric Metabolic Surgery Operations
Single Incision Laparoscopic Robotic and Endoscopic approaches are
available at patientsrsquo requests and the discretion of the surgeon
CHOICE OF PROCEDURE
The MOHAK Guide for Choice of Bariatric Metabolic Surgery Operations
Mohak Bariatrics and Robotics Surgery Center Motto
ldquoThe best operation for the patient by a competent surgeon in a well equipped hospital to maximize outcomes with the least amount of risks exposurerdquo
WE ARE ABLE TO CHOOSE THE BEST BARIATRIC METABOLIC PROCEDURE FOR YOUR PATIENT
Good long-term results are our marketing toolSuccessful patients make a lot of referralsbull
CHOICE OF PROCEDURE
The MOHAK Guide for Choice of Bariatric Metabolic Surgery Operations
We offer various treatment modalities for obesity The operation is
determined by the profile of the patient and guided by findings from
analysis of the data from our prospectively maintained database
MOHAK TEAM INDORE INDIA
THANK YOU
COMPARISON OF BGBP OAGB VS STD GBP
Outcome after the operations BGBP OAGBP STD GBP
Av Initial weight loss 1-3yrs gt77 gt77 65-70
Weight loss 4-10 years 70-77 70-77 55-65
Resolution of T2DM 80--85 80-90 60-80
VomitingSolid Food Intolerance 5-15 lt5 lt5
Diarrhea and Steatorrhea 1-2A 15-30 NA
Symptomatic Reflux 1-3 3-11 1-3
Marginal Ulcers 3-5 3-5 3-5
Protein Caloric Malnutrition lt1 3-11 lt1
Significant Weight regain 3-10 3-10 10-35
Ringband Erosion 0-1 NA NA
CHOICE OF PROCEDURE
We have enough information currently to enhance the outcome and minimize the risk by matching the operation to the patient
That is the basis forAn Algorithm for Bariatric Metabolic Operations
CHOOSING THE BEST BARIATRIC METABOLIC PROCEDURE FOR THE PATIENT
CHOICE OF PROCEDURE
bull All agesbull With no diabetesbull With low BMI preferably lt40bull With no GERDbull With HO PUDbull With HO or findings of liver diseasebull With Inflammatory bowel diseasebull With dense adhesions from multiple small bowel surgeriesbull Without HO VTEbull In heavy smokers who are not likely to quitbull In gastric cancer endemic areasbull High Risk needing minimal anesthesia and OR timebull High BMI gt 60 as part of a two stage approach
ALGORITHM
LSG BSG
CHOICE OF PROCEDURE
Laparoscopic Sleeve Gastrectomy Or Banded Sleeve Gastrostomy (SGBSD) Indicated for Patients
-All ages-Patients with T2DM lt5years and HbA1-c lt8 C-Peptidegt2 and not on insulin
-Patients with GERD
-ALL BMI ----- -BGBPBMIlt50-- LGBP
Vegetarian (BGBP)
BGBPLGBP
CHOICE OF PROCEDURE
ALGORITHM
Laparoscopic Gastric Bypass(LGBP) or Banded Gastric Bypass(BGBP) Indicated for Patients
bull With Diabetes gt5 years HbA1cgt8 C-Peptide lt2andor on Insulinbull All agesbull All BMI particularly High BMI-gt50bull High risk patients with need for short anesthesia timebull Because it is an easy to perform procedurebull Best tolerated by non Vegetarian
bull GERD Is a contraindicationbull Liver disease is a contraindication
Must be able to follow up patient regularlyPatient must be able to afford the required supplements OAGB
CHOICE OF PROCEDURE
ALGORITHM
OAGBMGB for patients
Sleeve gastrectomy with duodenal bypass(SGDJB) in patients with indication for Gastric Bypass in Gastric Cancer Endemic Areas
As effective as GBPSame weight loss andmetabolic effects as gastric bypass
SG-DJB
CHOICE OF PROCEDURE
ALGORITHM
Sleeve gastrectomy with duodenal bypass(SGDJB) in patients
1Second stage operation for the sleeve gastrectomy
2 Non responders or complications of sleeve gastric bypass or OAGBMGB
BPD-DS SADI SASI SG with enteral bypass
CHOICE OF PROCEDURE
ALGORITHM
BPD-DS SADI SAGI SASI) Indicated for
Areas with high incidence of anemia and very strict vegetarian food habits
CHOICE OF PROCEDURE
ALGORITHM
Sleeve Gastrectomy with gastro-jejunal gastro-ileal or entero-enteral anastomosis
Intra Gastric Balloon ENDOBARRIER
V-BLOC Aspire AssistEndoscopic Plication
For a patient who does not want an intra abdominal gastro-intestinal procedure
CHOICE OF PROCEDURE
Should You Do A Bariatric Metabolic Operation Because That Is What The Patient Wantsrdquo
NOYESmdashIt depends HoweverA bariatric metabolic surgeon should be able to offer the best operation for the patient based on the patientrsquos profile It is good practice to refer the patient to a tertiary center if the surgeon does not offer the operation that meets the patients indication
CHOICE OF PROCEDURE
CHOOSING THE BEST BARIATRIC METABOLIC PROCEDURE FOR THE PATIENT
CHOICE OF PROCEDURE
Case 157 yo Male BMI 57KgM2 T2DM GERD Strict Vegetarian
Algorithm
Gastric bypass-----Preferably Banded gastric bypassmdash------GERD Vegetarian
Not Sleeve because of T2DM GERD and High BMI
Not OAGBMGB because of GERD and probable of protein deficiency
CHOOSING THE BEST BARIATRIC METABOLIC PROCEDURE FOR THE PATIENT
CHOICE OF PROCEDURE
Case 1128 y0 F BMI 42 PCO DUB OSA and HO Migraine headaches
AlgorithmSleeve GastrectomymdashPreferably a Ring banded Sleeve gastrectomy
----No T2DM---No GERDNot Gastric bypass mdash anemia smelly flatus
Not OAGBMGB----Anemia Foul smelling flatus and body odor----Protein deficiency
CHOOSING THE BEST BARIATRIC METABOLIC PROCEDURE FOR THE PATIENT
CHOICE OF PROCEDURE
Case 11137 yo Male BMI 68 OSA OA and a non vegetarian who works at your hospitalReferred by the pulmonologist at your medical Centre
Algorithm
OAGBMGBmdashHigh BMI Non Veg-better food tolerance patient very likely to be followedand to afford the supplements because of proximity to your center
Not sleeve---poor weight loss with sleeve in super obeseNot Banded sleeve---Good weight loss but poor food tolerance since patient is a non vegetarianNot Gastric bypass---Weight loss in super obese have high non response after gastric bypass
and the gastric bypass is technically a more difficult operation than the OAGBNot Banded gastric bypass ndashGood weight loss but a BGBP is a more difficult operation and
the patient will have some food intolerance because of the ring
SURGICAL TREATMENT OPTIONS
At Mohak we perform these standard three operations and their banded modifications
Sleeve Gastrectomy Gastric Bypass OAGBMGB
CHOICE OF PROCEDURE
Evidence based operations performed at MBRSC From 2010 t0 2017---Standardized OperationsLaparoscopic Sleeve Gastrectomybull 90-120 cc Sleevebull 2-5cm from pylorusbull Where a sleeve is indicated but a band is contraindicated or not affordableBanded Sleeve Gastrectomy (BSG) 84 EWL after 60 monthsbull 90-120 cc Sleevebull 2-5cm from pylorusbull Ring 65-75 cmbull At 3-6 cm below GE junctionBanded Gastric bypass (BGBP) 75 EWL 48 monthsbull Create 6mdash7cm long pouchbull 65-75 cm ring at 3-5 cm below GE junction and gt2cm above anastomosisbull Large Gastroenterostomy gt 2cm bull 100cm Roux Limb and 80 cm BP limb for BMIlt50bull 100cm Roux Limb and 150 cm BP limb for BMIgt50Mini-Gastric Bypass (MGB) (OAGB) 79 EWL 60 monthsbull 9-18cm long pouch ~25cm widebull BP Limb length of 180cm BMIlt50Banded Mini-Gastric Bypass(BMGB)(BOAGB)bull 9-18cm long pouch ~25cm widebull Ring 7-75 cmbull BP Limb length of 180cm BMI50
THE MOHAK PROTOCOLStandardized Bariatric and Robotic Surgery Operations
CHOICE OF PROCEDURE
Sleeve Gastrectomy (LSG) or Banded Sleeve Gastrectomy (BSG)bull Non-diabeticsbull No hiatal hernia or GERDbull HO Smokingbull HO alcohol usebull HO PUDbull Abnormal LFTs NASH and early Cirrhosisbull Pts from areas with high incidence of gastric cancer of H pylori infectionbull High risks patients and super obese patients as part of a two-staged operation
Gastric Bypass (LGBP) or Banded Gastric Bypass (BGBP) or Hybrid BGBPMGBbull Have T2DM with HgbA1c lt 8 and duration lt 5 yearsbull Have Hiatal hernia or GERDbull Are Vegetarianbull No nicotine addiction (smoking)bull Have HO Alcohol intake bull Have NASH at surgery-No cirrhosisbull Not likely to come back for follow up andbull Revision operation of Failed Sleeve gastrectomy GBP or MGB
MOHAK ALGORITHM
CHOICE OF PROCEDURE
One Anastomosis Gastric Bypass-Mini-Gastric Bypass (OAGBP-MGB) bull Have T2DM with HgbA1c 8 and durationgt5 yearsbull Have No GERDbull Are Non-vegetarianbull Have poor dentitionbull Most likely to return for follow up at the clinicbull No HO alcohol intakebull No Nicotine addiction (smoking)bull Normal LFTsbull No NASH at surgery or cirrhosisbull Commitment by our program to have 100 follow up of theses patient
Revision Operationbull Sleeve to Banded RY with 100 cm Al limb and 180 cm BP Limbbull MGB to diverted MGB for Reflux Existing BPL and 100cm ALbull MGB to GBP for PCM or reversal to normal anatomy for PCMmdashinterim gastrostomy feedingbull GBP to BGBP with 180cm BP limb for Weight regain or inadequate weight loss BMIlt40bull GBP to BGBP with 300cm common limb for Weight regain or inadequate weight loss BMIgt40
MOHAK ALGORITHM
CHOICE OF PROCEDURE
bull Laparoscopic Gastric Bypass
bull Laparoscopic Sleeve Gastrectomy
bull Divided Mini-Gastric Bypass
bull Biliopancreatic Diversion with DS
bull Single Anastomosis Duodeno-ileostomy
bull Gastric Plication
bull Banded Gastric Plication
bull Endoscopic Gastroplasty
bull Laparoscopic Adjustable Gastric bands
bull Balloon Implantation
bull Ileal interposition
These other operations will be used selectively based on patients needs and the surgeons determination
CHOICE OF PROCEDURE
The MOHAK Guide for Choice of Bariatric Metabolic Surgery Operations
Single Incision Laparoscopic Robotic and Endoscopic approaches are
available at patientsrsquo requests and the discretion of the surgeon
CHOICE OF PROCEDURE
The MOHAK Guide for Choice of Bariatric Metabolic Surgery Operations
Mohak Bariatrics and Robotics Surgery Center Motto
ldquoThe best operation for the patient by a competent surgeon in a well equipped hospital to maximize outcomes with the least amount of risks exposurerdquo
WE ARE ABLE TO CHOOSE THE BEST BARIATRIC METABOLIC PROCEDURE FOR YOUR PATIENT
Good long-term results are our marketing toolSuccessful patients make a lot of referralsbull
CHOICE OF PROCEDURE
The MOHAK Guide for Choice of Bariatric Metabolic Surgery Operations
We offer various treatment modalities for obesity The operation is
determined by the profile of the patient and guided by findings from
analysis of the data from our prospectively maintained database
MOHAK TEAM INDORE INDIA
THANK YOU
We have enough information currently to enhance the outcome and minimize the risk by matching the operation to the patient
That is the basis forAn Algorithm for Bariatric Metabolic Operations
CHOOSING THE BEST BARIATRIC METABOLIC PROCEDURE FOR THE PATIENT
CHOICE OF PROCEDURE
bull All agesbull With no diabetesbull With low BMI preferably lt40bull With no GERDbull With HO PUDbull With HO or findings of liver diseasebull With Inflammatory bowel diseasebull With dense adhesions from multiple small bowel surgeriesbull Without HO VTEbull In heavy smokers who are not likely to quitbull In gastric cancer endemic areasbull High Risk needing minimal anesthesia and OR timebull High BMI gt 60 as part of a two stage approach
ALGORITHM
LSG BSG
CHOICE OF PROCEDURE
Laparoscopic Sleeve Gastrectomy Or Banded Sleeve Gastrostomy (SGBSD) Indicated for Patients
-All ages-Patients with T2DM lt5years and HbA1-c lt8 C-Peptidegt2 and not on insulin
-Patients with GERD
-ALL BMI ----- -BGBPBMIlt50-- LGBP
Vegetarian (BGBP)
BGBPLGBP
CHOICE OF PROCEDURE
ALGORITHM
Laparoscopic Gastric Bypass(LGBP) or Banded Gastric Bypass(BGBP) Indicated for Patients
bull With Diabetes gt5 years HbA1cgt8 C-Peptide lt2andor on Insulinbull All agesbull All BMI particularly High BMI-gt50bull High risk patients with need for short anesthesia timebull Because it is an easy to perform procedurebull Best tolerated by non Vegetarian
bull GERD Is a contraindicationbull Liver disease is a contraindication
Must be able to follow up patient regularlyPatient must be able to afford the required supplements OAGB
CHOICE OF PROCEDURE
ALGORITHM
OAGBMGB for patients
Sleeve gastrectomy with duodenal bypass(SGDJB) in patients with indication for Gastric Bypass in Gastric Cancer Endemic Areas
As effective as GBPSame weight loss andmetabolic effects as gastric bypass
SG-DJB
CHOICE OF PROCEDURE
ALGORITHM
Sleeve gastrectomy with duodenal bypass(SGDJB) in patients
1Second stage operation for the sleeve gastrectomy
2 Non responders or complications of sleeve gastric bypass or OAGBMGB
BPD-DS SADI SASI SG with enteral bypass
CHOICE OF PROCEDURE
ALGORITHM
BPD-DS SADI SAGI SASI) Indicated for
Areas with high incidence of anemia and very strict vegetarian food habits
CHOICE OF PROCEDURE
ALGORITHM
Sleeve Gastrectomy with gastro-jejunal gastro-ileal or entero-enteral anastomosis
Intra Gastric Balloon ENDOBARRIER
V-BLOC Aspire AssistEndoscopic Plication
For a patient who does not want an intra abdominal gastro-intestinal procedure
CHOICE OF PROCEDURE
Should You Do A Bariatric Metabolic Operation Because That Is What The Patient Wantsrdquo
NOYESmdashIt depends HoweverA bariatric metabolic surgeon should be able to offer the best operation for the patient based on the patientrsquos profile It is good practice to refer the patient to a tertiary center if the surgeon does not offer the operation that meets the patients indication
CHOICE OF PROCEDURE
CHOOSING THE BEST BARIATRIC METABOLIC PROCEDURE FOR THE PATIENT
CHOICE OF PROCEDURE
Case 157 yo Male BMI 57KgM2 T2DM GERD Strict Vegetarian
Algorithm
Gastric bypass-----Preferably Banded gastric bypassmdash------GERD Vegetarian
Not Sleeve because of T2DM GERD and High BMI
Not OAGBMGB because of GERD and probable of protein deficiency
CHOOSING THE BEST BARIATRIC METABOLIC PROCEDURE FOR THE PATIENT
CHOICE OF PROCEDURE
Case 1128 y0 F BMI 42 PCO DUB OSA and HO Migraine headaches
AlgorithmSleeve GastrectomymdashPreferably a Ring banded Sleeve gastrectomy
----No T2DM---No GERDNot Gastric bypass mdash anemia smelly flatus
Not OAGBMGB----Anemia Foul smelling flatus and body odor----Protein deficiency
CHOOSING THE BEST BARIATRIC METABOLIC PROCEDURE FOR THE PATIENT
CHOICE OF PROCEDURE
Case 11137 yo Male BMI 68 OSA OA and a non vegetarian who works at your hospitalReferred by the pulmonologist at your medical Centre
Algorithm
OAGBMGBmdashHigh BMI Non Veg-better food tolerance patient very likely to be followedand to afford the supplements because of proximity to your center
Not sleeve---poor weight loss with sleeve in super obeseNot Banded sleeve---Good weight loss but poor food tolerance since patient is a non vegetarianNot Gastric bypass---Weight loss in super obese have high non response after gastric bypass
and the gastric bypass is technically a more difficult operation than the OAGBNot Banded gastric bypass ndashGood weight loss but a BGBP is a more difficult operation and
the patient will have some food intolerance because of the ring
SURGICAL TREATMENT OPTIONS
At Mohak we perform these standard three operations and their banded modifications
Sleeve Gastrectomy Gastric Bypass OAGBMGB
CHOICE OF PROCEDURE
Evidence based operations performed at MBRSC From 2010 t0 2017---Standardized OperationsLaparoscopic Sleeve Gastrectomybull 90-120 cc Sleevebull 2-5cm from pylorusbull Where a sleeve is indicated but a band is contraindicated or not affordableBanded Sleeve Gastrectomy (BSG) 84 EWL after 60 monthsbull 90-120 cc Sleevebull 2-5cm from pylorusbull Ring 65-75 cmbull At 3-6 cm below GE junctionBanded Gastric bypass (BGBP) 75 EWL 48 monthsbull Create 6mdash7cm long pouchbull 65-75 cm ring at 3-5 cm below GE junction and gt2cm above anastomosisbull Large Gastroenterostomy gt 2cm bull 100cm Roux Limb and 80 cm BP limb for BMIlt50bull 100cm Roux Limb and 150 cm BP limb for BMIgt50Mini-Gastric Bypass (MGB) (OAGB) 79 EWL 60 monthsbull 9-18cm long pouch ~25cm widebull BP Limb length of 180cm BMIlt50Banded Mini-Gastric Bypass(BMGB)(BOAGB)bull 9-18cm long pouch ~25cm widebull Ring 7-75 cmbull BP Limb length of 180cm BMI50
THE MOHAK PROTOCOLStandardized Bariatric and Robotic Surgery Operations
CHOICE OF PROCEDURE
Sleeve Gastrectomy (LSG) or Banded Sleeve Gastrectomy (BSG)bull Non-diabeticsbull No hiatal hernia or GERDbull HO Smokingbull HO alcohol usebull HO PUDbull Abnormal LFTs NASH and early Cirrhosisbull Pts from areas with high incidence of gastric cancer of H pylori infectionbull High risks patients and super obese patients as part of a two-staged operation
Gastric Bypass (LGBP) or Banded Gastric Bypass (BGBP) or Hybrid BGBPMGBbull Have T2DM with HgbA1c lt 8 and duration lt 5 yearsbull Have Hiatal hernia or GERDbull Are Vegetarianbull No nicotine addiction (smoking)bull Have HO Alcohol intake bull Have NASH at surgery-No cirrhosisbull Not likely to come back for follow up andbull Revision operation of Failed Sleeve gastrectomy GBP or MGB
MOHAK ALGORITHM
CHOICE OF PROCEDURE
One Anastomosis Gastric Bypass-Mini-Gastric Bypass (OAGBP-MGB) bull Have T2DM with HgbA1c 8 and durationgt5 yearsbull Have No GERDbull Are Non-vegetarianbull Have poor dentitionbull Most likely to return for follow up at the clinicbull No HO alcohol intakebull No Nicotine addiction (smoking)bull Normal LFTsbull No NASH at surgery or cirrhosisbull Commitment by our program to have 100 follow up of theses patient
Revision Operationbull Sleeve to Banded RY with 100 cm Al limb and 180 cm BP Limbbull MGB to diverted MGB for Reflux Existing BPL and 100cm ALbull MGB to GBP for PCM or reversal to normal anatomy for PCMmdashinterim gastrostomy feedingbull GBP to BGBP with 180cm BP limb for Weight regain or inadequate weight loss BMIlt40bull GBP to BGBP with 300cm common limb for Weight regain or inadequate weight loss BMIgt40
MOHAK ALGORITHM
CHOICE OF PROCEDURE
bull Laparoscopic Gastric Bypass
bull Laparoscopic Sleeve Gastrectomy
bull Divided Mini-Gastric Bypass
bull Biliopancreatic Diversion with DS
bull Single Anastomosis Duodeno-ileostomy
bull Gastric Plication
bull Banded Gastric Plication
bull Endoscopic Gastroplasty
bull Laparoscopic Adjustable Gastric bands
bull Balloon Implantation
bull Ileal interposition
These other operations will be used selectively based on patients needs and the surgeons determination
CHOICE OF PROCEDURE
The MOHAK Guide for Choice of Bariatric Metabolic Surgery Operations
Single Incision Laparoscopic Robotic and Endoscopic approaches are
available at patientsrsquo requests and the discretion of the surgeon
CHOICE OF PROCEDURE
The MOHAK Guide for Choice of Bariatric Metabolic Surgery Operations
Mohak Bariatrics and Robotics Surgery Center Motto
ldquoThe best operation for the patient by a competent surgeon in a well equipped hospital to maximize outcomes with the least amount of risks exposurerdquo
WE ARE ABLE TO CHOOSE THE BEST BARIATRIC METABOLIC PROCEDURE FOR YOUR PATIENT
Good long-term results are our marketing toolSuccessful patients make a lot of referralsbull
CHOICE OF PROCEDURE
The MOHAK Guide for Choice of Bariatric Metabolic Surgery Operations
We offer various treatment modalities for obesity The operation is
determined by the profile of the patient and guided by findings from
analysis of the data from our prospectively maintained database
MOHAK TEAM INDORE INDIA
THANK YOU
bull All agesbull With no diabetesbull With low BMI preferably lt40bull With no GERDbull With HO PUDbull With HO or findings of liver diseasebull With Inflammatory bowel diseasebull With dense adhesions from multiple small bowel surgeriesbull Without HO VTEbull In heavy smokers who are not likely to quitbull In gastric cancer endemic areasbull High Risk needing minimal anesthesia and OR timebull High BMI gt 60 as part of a two stage approach
ALGORITHM
LSG BSG
CHOICE OF PROCEDURE
Laparoscopic Sleeve Gastrectomy Or Banded Sleeve Gastrostomy (SGBSD) Indicated for Patients
-All ages-Patients with T2DM lt5years and HbA1-c lt8 C-Peptidegt2 and not on insulin
-Patients with GERD
-ALL BMI ----- -BGBPBMIlt50-- LGBP
Vegetarian (BGBP)
BGBPLGBP
CHOICE OF PROCEDURE
ALGORITHM
Laparoscopic Gastric Bypass(LGBP) or Banded Gastric Bypass(BGBP) Indicated for Patients
bull With Diabetes gt5 years HbA1cgt8 C-Peptide lt2andor on Insulinbull All agesbull All BMI particularly High BMI-gt50bull High risk patients with need for short anesthesia timebull Because it is an easy to perform procedurebull Best tolerated by non Vegetarian
bull GERD Is a contraindicationbull Liver disease is a contraindication
Must be able to follow up patient regularlyPatient must be able to afford the required supplements OAGB
CHOICE OF PROCEDURE
ALGORITHM
OAGBMGB for patients
Sleeve gastrectomy with duodenal bypass(SGDJB) in patients with indication for Gastric Bypass in Gastric Cancer Endemic Areas
As effective as GBPSame weight loss andmetabolic effects as gastric bypass
SG-DJB
CHOICE OF PROCEDURE
ALGORITHM
Sleeve gastrectomy with duodenal bypass(SGDJB) in patients
1Second stage operation for the sleeve gastrectomy
2 Non responders or complications of sleeve gastric bypass or OAGBMGB
BPD-DS SADI SASI SG with enteral bypass
CHOICE OF PROCEDURE
ALGORITHM
BPD-DS SADI SAGI SASI) Indicated for
Areas with high incidence of anemia and very strict vegetarian food habits
CHOICE OF PROCEDURE
ALGORITHM
Sleeve Gastrectomy with gastro-jejunal gastro-ileal or entero-enteral anastomosis
Intra Gastric Balloon ENDOBARRIER
V-BLOC Aspire AssistEndoscopic Plication
For a patient who does not want an intra abdominal gastro-intestinal procedure
CHOICE OF PROCEDURE
Should You Do A Bariatric Metabolic Operation Because That Is What The Patient Wantsrdquo
NOYESmdashIt depends HoweverA bariatric metabolic surgeon should be able to offer the best operation for the patient based on the patientrsquos profile It is good practice to refer the patient to a tertiary center if the surgeon does not offer the operation that meets the patients indication
CHOICE OF PROCEDURE
CHOOSING THE BEST BARIATRIC METABOLIC PROCEDURE FOR THE PATIENT
CHOICE OF PROCEDURE
Case 157 yo Male BMI 57KgM2 T2DM GERD Strict Vegetarian
Algorithm
Gastric bypass-----Preferably Banded gastric bypassmdash------GERD Vegetarian
Not Sleeve because of T2DM GERD and High BMI
Not OAGBMGB because of GERD and probable of protein deficiency
CHOOSING THE BEST BARIATRIC METABOLIC PROCEDURE FOR THE PATIENT
CHOICE OF PROCEDURE
Case 1128 y0 F BMI 42 PCO DUB OSA and HO Migraine headaches
AlgorithmSleeve GastrectomymdashPreferably a Ring banded Sleeve gastrectomy
----No T2DM---No GERDNot Gastric bypass mdash anemia smelly flatus
Not OAGBMGB----Anemia Foul smelling flatus and body odor----Protein deficiency
CHOOSING THE BEST BARIATRIC METABOLIC PROCEDURE FOR THE PATIENT
CHOICE OF PROCEDURE
Case 11137 yo Male BMI 68 OSA OA and a non vegetarian who works at your hospitalReferred by the pulmonologist at your medical Centre
Algorithm
OAGBMGBmdashHigh BMI Non Veg-better food tolerance patient very likely to be followedand to afford the supplements because of proximity to your center
Not sleeve---poor weight loss with sleeve in super obeseNot Banded sleeve---Good weight loss but poor food tolerance since patient is a non vegetarianNot Gastric bypass---Weight loss in super obese have high non response after gastric bypass
and the gastric bypass is technically a more difficult operation than the OAGBNot Banded gastric bypass ndashGood weight loss but a BGBP is a more difficult operation and
the patient will have some food intolerance because of the ring
SURGICAL TREATMENT OPTIONS
At Mohak we perform these standard three operations and their banded modifications
Sleeve Gastrectomy Gastric Bypass OAGBMGB
CHOICE OF PROCEDURE
Evidence based operations performed at MBRSC From 2010 t0 2017---Standardized OperationsLaparoscopic Sleeve Gastrectomybull 90-120 cc Sleevebull 2-5cm from pylorusbull Where a sleeve is indicated but a band is contraindicated or not affordableBanded Sleeve Gastrectomy (BSG) 84 EWL after 60 monthsbull 90-120 cc Sleevebull 2-5cm from pylorusbull Ring 65-75 cmbull At 3-6 cm below GE junctionBanded Gastric bypass (BGBP) 75 EWL 48 monthsbull Create 6mdash7cm long pouchbull 65-75 cm ring at 3-5 cm below GE junction and gt2cm above anastomosisbull Large Gastroenterostomy gt 2cm bull 100cm Roux Limb and 80 cm BP limb for BMIlt50bull 100cm Roux Limb and 150 cm BP limb for BMIgt50Mini-Gastric Bypass (MGB) (OAGB) 79 EWL 60 monthsbull 9-18cm long pouch ~25cm widebull BP Limb length of 180cm BMIlt50Banded Mini-Gastric Bypass(BMGB)(BOAGB)bull 9-18cm long pouch ~25cm widebull Ring 7-75 cmbull BP Limb length of 180cm BMI50
THE MOHAK PROTOCOLStandardized Bariatric and Robotic Surgery Operations
CHOICE OF PROCEDURE
Sleeve Gastrectomy (LSG) or Banded Sleeve Gastrectomy (BSG)bull Non-diabeticsbull No hiatal hernia or GERDbull HO Smokingbull HO alcohol usebull HO PUDbull Abnormal LFTs NASH and early Cirrhosisbull Pts from areas with high incidence of gastric cancer of H pylori infectionbull High risks patients and super obese patients as part of a two-staged operation
Gastric Bypass (LGBP) or Banded Gastric Bypass (BGBP) or Hybrid BGBPMGBbull Have T2DM with HgbA1c lt 8 and duration lt 5 yearsbull Have Hiatal hernia or GERDbull Are Vegetarianbull No nicotine addiction (smoking)bull Have HO Alcohol intake bull Have NASH at surgery-No cirrhosisbull Not likely to come back for follow up andbull Revision operation of Failed Sleeve gastrectomy GBP or MGB
MOHAK ALGORITHM
CHOICE OF PROCEDURE
One Anastomosis Gastric Bypass-Mini-Gastric Bypass (OAGBP-MGB) bull Have T2DM with HgbA1c 8 and durationgt5 yearsbull Have No GERDbull Are Non-vegetarianbull Have poor dentitionbull Most likely to return for follow up at the clinicbull No HO alcohol intakebull No Nicotine addiction (smoking)bull Normal LFTsbull No NASH at surgery or cirrhosisbull Commitment by our program to have 100 follow up of theses patient
Revision Operationbull Sleeve to Banded RY with 100 cm Al limb and 180 cm BP Limbbull MGB to diverted MGB for Reflux Existing BPL and 100cm ALbull MGB to GBP for PCM or reversal to normal anatomy for PCMmdashinterim gastrostomy feedingbull GBP to BGBP with 180cm BP limb for Weight regain or inadequate weight loss BMIlt40bull GBP to BGBP with 300cm common limb for Weight regain or inadequate weight loss BMIgt40
MOHAK ALGORITHM
CHOICE OF PROCEDURE
bull Laparoscopic Gastric Bypass
bull Laparoscopic Sleeve Gastrectomy
bull Divided Mini-Gastric Bypass
bull Biliopancreatic Diversion with DS
bull Single Anastomosis Duodeno-ileostomy
bull Gastric Plication
bull Banded Gastric Plication
bull Endoscopic Gastroplasty
bull Laparoscopic Adjustable Gastric bands
bull Balloon Implantation
bull Ileal interposition
These other operations will be used selectively based on patients needs and the surgeons determination
CHOICE OF PROCEDURE
The MOHAK Guide for Choice of Bariatric Metabolic Surgery Operations
Single Incision Laparoscopic Robotic and Endoscopic approaches are
available at patientsrsquo requests and the discretion of the surgeon
CHOICE OF PROCEDURE
The MOHAK Guide for Choice of Bariatric Metabolic Surgery Operations
Mohak Bariatrics and Robotics Surgery Center Motto
ldquoThe best operation for the patient by a competent surgeon in a well equipped hospital to maximize outcomes with the least amount of risks exposurerdquo
WE ARE ABLE TO CHOOSE THE BEST BARIATRIC METABOLIC PROCEDURE FOR YOUR PATIENT
Good long-term results are our marketing toolSuccessful patients make a lot of referralsbull
CHOICE OF PROCEDURE
The MOHAK Guide for Choice of Bariatric Metabolic Surgery Operations
We offer various treatment modalities for obesity The operation is
determined by the profile of the patient and guided by findings from
analysis of the data from our prospectively maintained database
MOHAK TEAM INDORE INDIA
THANK YOU
-All ages-Patients with T2DM lt5years and HbA1-c lt8 C-Peptidegt2 and not on insulin
-Patients with GERD
-ALL BMI ----- -BGBPBMIlt50-- LGBP
Vegetarian (BGBP)
BGBPLGBP
CHOICE OF PROCEDURE
ALGORITHM
Laparoscopic Gastric Bypass(LGBP) or Banded Gastric Bypass(BGBP) Indicated for Patients
bull With Diabetes gt5 years HbA1cgt8 C-Peptide lt2andor on Insulinbull All agesbull All BMI particularly High BMI-gt50bull High risk patients with need for short anesthesia timebull Because it is an easy to perform procedurebull Best tolerated by non Vegetarian
bull GERD Is a contraindicationbull Liver disease is a contraindication
Must be able to follow up patient regularlyPatient must be able to afford the required supplements OAGB
CHOICE OF PROCEDURE
ALGORITHM
OAGBMGB for patients
Sleeve gastrectomy with duodenal bypass(SGDJB) in patients with indication for Gastric Bypass in Gastric Cancer Endemic Areas
As effective as GBPSame weight loss andmetabolic effects as gastric bypass
SG-DJB
CHOICE OF PROCEDURE
ALGORITHM
Sleeve gastrectomy with duodenal bypass(SGDJB) in patients
1Second stage operation for the sleeve gastrectomy
2 Non responders or complications of sleeve gastric bypass or OAGBMGB
BPD-DS SADI SASI SG with enteral bypass
CHOICE OF PROCEDURE
ALGORITHM
BPD-DS SADI SAGI SASI) Indicated for
Areas with high incidence of anemia and very strict vegetarian food habits
CHOICE OF PROCEDURE
ALGORITHM
Sleeve Gastrectomy with gastro-jejunal gastro-ileal or entero-enteral anastomosis
Intra Gastric Balloon ENDOBARRIER
V-BLOC Aspire AssistEndoscopic Plication
For a patient who does not want an intra abdominal gastro-intestinal procedure
CHOICE OF PROCEDURE
Should You Do A Bariatric Metabolic Operation Because That Is What The Patient Wantsrdquo
NOYESmdashIt depends HoweverA bariatric metabolic surgeon should be able to offer the best operation for the patient based on the patientrsquos profile It is good practice to refer the patient to a tertiary center if the surgeon does not offer the operation that meets the patients indication
CHOICE OF PROCEDURE
CHOOSING THE BEST BARIATRIC METABOLIC PROCEDURE FOR THE PATIENT
CHOICE OF PROCEDURE
Case 157 yo Male BMI 57KgM2 T2DM GERD Strict Vegetarian
Algorithm
Gastric bypass-----Preferably Banded gastric bypassmdash------GERD Vegetarian
Not Sleeve because of T2DM GERD and High BMI
Not OAGBMGB because of GERD and probable of protein deficiency
CHOOSING THE BEST BARIATRIC METABOLIC PROCEDURE FOR THE PATIENT
CHOICE OF PROCEDURE
Case 1128 y0 F BMI 42 PCO DUB OSA and HO Migraine headaches
AlgorithmSleeve GastrectomymdashPreferably a Ring banded Sleeve gastrectomy
----No T2DM---No GERDNot Gastric bypass mdash anemia smelly flatus
Not OAGBMGB----Anemia Foul smelling flatus and body odor----Protein deficiency
CHOOSING THE BEST BARIATRIC METABOLIC PROCEDURE FOR THE PATIENT
CHOICE OF PROCEDURE
Case 11137 yo Male BMI 68 OSA OA and a non vegetarian who works at your hospitalReferred by the pulmonologist at your medical Centre
Algorithm
OAGBMGBmdashHigh BMI Non Veg-better food tolerance patient very likely to be followedand to afford the supplements because of proximity to your center
Not sleeve---poor weight loss with sleeve in super obeseNot Banded sleeve---Good weight loss but poor food tolerance since patient is a non vegetarianNot Gastric bypass---Weight loss in super obese have high non response after gastric bypass
and the gastric bypass is technically a more difficult operation than the OAGBNot Banded gastric bypass ndashGood weight loss but a BGBP is a more difficult operation and
the patient will have some food intolerance because of the ring
SURGICAL TREATMENT OPTIONS
At Mohak we perform these standard three operations and their banded modifications
Sleeve Gastrectomy Gastric Bypass OAGBMGB
CHOICE OF PROCEDURE
Evidence based operations performed at MBRSC From 2010 t0 2017---Standardized OperationsLaparoscopic Sleeve Gastrectomybull 90-120 cc Sleevebull 2-5cm from pylorusbull Where a sleeve is indicated but a band is contraindicated or not affordableBanded Sleeve Gastrectomy (BSG) 84 EWL after 60 monthsbull 90-120 cc Sleevebull 2-5cm from pylorusbull Ring 65-75 cmbull At 3-6 cm below GE junctionBanded Gastric bypass (BGBP) 75 EWL 48 monthsbull Create 6mdash7cm long pouchbull 65-75 cm ring at 3-5 cm below GE junction and gt2cm above anastomosisbull Large Gastroenterostomy gt 2cm bull 100cm Roux Limb and 80 cm BP limb for BMIlt50bull 100cm Roux Limb and 150 cm BP limb for BMIgt50Mini-Gastric Bypass (MGB) (OAGB) 79 EWL 60 monthsbull 9-18cm long pouch ~25cm widebull BP Limb length of 180cm BMIlt50Banded Mini-Gastric Bypass(BMGB)(BOAGB)bull 9-18cm long pouch ~25cm widebull Ring 7-75 cmbull BP Limb length of 180cm BMI50
THE MOHAK PROTOCOLStandardized Bariatric and Robotic Surgery Operations
CHOICE OF PROCEDURE
Sleeve Gastrectomy (LSG) or Banded Sleeve Gastrectomy (BSG)bull Non-diabeticsbull No hiatal hernia or GERDbull HO Smokingbull HO alcohol usebull HO PUDbull Abnormal LFTs NASH and early Cirrhosisbull Pts from areas with high incidence of gastric cancer of H pylori infectionbull High risks patients and super obese patients as part of a two-staged operation
Gastric Bypass (LGBP) or Banded Gastric Bypass (BGBP) or Hybrid BGBPMGBbull Have T2DM with HgbA1c lt 8 and duration lt 5 yearsbull Have Hiatal hernia or GERDbull Are Vegetarianbull No nicotine addiction (smoking)bull Have HO Alcohol intake bull Have NASH at surgery-No cirrhosisbull Not likely to come back for follow up andbull Revision operation of Failed Sleeve gastrectomy GBP or MGB
MOHAK ALGORITHM
CHOICE OF PROCEDURE
One Anastomosis Gastric Bypass-Mini-Gastric Bypass (OAGBP-MGB) bull Have T2DM with HgbA1c 8 and durationgt5 yearsbull Have No GERDbull Are Non-vegetarianbull Have poor dentitionbull Most likely to return for follow up at the clinicbull No HO alcohol intakebull No Nicotine addiction (smoking)bull Normal LFTsbull No NASH at surgery or cirrhosisbull Commitment by our program to have 100 follow up of theses patient
Revision Operationbull Sleeve to Banded RY with 100 cm Al limb and 180 cm BP Limbbull MGB to diverted MGB for Reflux Existing BPL and 100cm ALbull MGB to GBP for PCM or reversal to normal anatomy for PCMmdashinterim gastrostomy feedingbull GBP to BGBP with 180cm BP limb for Weight regain or inadequate weight loss BMIlt40bull GBP to BGBP with 300cm common limb for Weight regain or inadequate weight loss BMIgt40
MOHAK ALGORITHM
CHOICE OF PROCEDURE
bull Laparoscopic Gastric Bypass
bull Laparoscopic Sleeve Gastrectomy
bull Divided Mini-Gastric Bypass
bull Biliopancreatic Diversion with DS
bull Single Anastomosis Duodeno-ileostomy
bull Gastric Plication
bull Banded Gastric Plication
bull Endoscopic Gastroplasty
bull Laparoscopic Adjustable Gastric bands
bull Balloon Implantation
bull Ileal interposition
These other operations will be used selectively based on patients needs and the surgeons determination
CHOICE OF PROCEDURE
The MOHAK Guide for Choice of Bariatric Metabolic Surgery Operations
Single Incision Laparoscopic Robotic and Endoscopic approaches are
available at patientsrsquo requests and the discretion of the surgeon
CHOICE OF PROCEDURE
The MOHAK Guide for Choice of Bariatric Metabolic Surgery Operations
Mohak Bariatrics and Robotics Surgery Center Motto
ldquoThe best operation for the patient by a competent surgeon in a well equipped hospital to maximize outcomes with the least amount of risks exposurerdquo
WE ARE ABLE TO CHOOSE THE BEST BARIATRIC METABOLIC PROCEDURE FOR YOUR PATIENT
Good long-term results are our marketing toolSuccessful patients make a lot of referralsbull
CHOICE OF PROCEDURE
The MOHAK Guide for Choice of Bariatric Metabolic Surgery Operations
We offer various treatment modalities for obesity The operation is
determined by the profile of the patient and guided by findings from
analysis of the data from our prospectively maintained database
MOHAK TEAM INDORE INDIA
THANK YOU
bull With Diabetes gt5 years HbA1cgt8 C-Peptide lt2andor on Insulinbull All agesbull All BMI particularly High BMI-gt50bull High risk patients with need for short anesthesia timebull Because it is an easy to perform procedurebull Best tolerated by non Vegetarian
bull GERD Is a contraindicationbull Liver disease is a contraindication
Must be able to follow up patient regularlyPatient must be able to afford the required supplements OAGB
CHOICE OF PROCEDURE
ALGORITHM
OAGBMGB for patients
Sleeve gastrectomy with duodenal bypass(SGDJB) in patients with indication for Gastric Bypass in Gastric Cancer Endemic Areas
As effective as GBPSame weight loss andmetabolic effects as gastric bypass
SG-DJB
CHOICE OF PROCEDURE
ALGORITHM
Sleeve gastrectomy with duodenal bypass(SGDJB) in patients
1Second stage operation for the sleeve gastrectomy
2 Non responders or complications of sleeve gastric bypass or OAGBMGB
BPD-DS SADI SASI SG with enteral bypass
CHOICE OF PROCEDURE
ALGORITHM
BPD-DS SADI SAGI SASI) Indicated for
Areas with high incidence of anemia and very strict vegetarian food habits
CHOICE OF PROCEDURE
ALGORITHM
Sleeve Gastrectomy with gastro-jejunal gastro-ileal or entero-enteral anastomosis
Intra Gastric Balloon ENDOBARRIER
V-BLOC Aspire AssistEndoscopic Plication
For a patient who does not want an intra abdominal gastro-intestinal procedure
CHOICE OF PROCEDURE
Should You Do A Bariatric Metabolic Operation Because That Is What The Patient Wantsrdquo
NOYESmdashIt depends HoweverA bariatric metabolic surgeon should be able to offer the best operation for the patient based on the patientrsquos profile It is good practice to refer the patient to a tertiary center if the surgeon does not offer the operation that meets the patients indication
CHOICE OF PROCEDURE
CHOOSING THE BEST BARIATRIC METABOLIC PROCEDURE FOR THE PATIENT
CHOICE OF PROCEDURE
Case 157 yo Male BMI 57KgM2 T2DM GERD Strict Vegetarian
Algorithm
Gastric bypass-----Preferably Banded gastric bypassmdash------GERD Vegetarian
Not Sleeve because of T2DM GERD and High BMI
Not OAGBMGB because of GERD and probable of protein deficiency
CHOOSING THE BEST BARIATRIC METABOLIC PROCEDURE FOR THE PATIENT
CHOICE OF PROCEDURE
Case 1128 y0 F BMI 42 PCO DUB OSA and HO Migraine headaches
AlgorithmSleeve GastrectomymdashPreferably a Ring banded Sleeve gastrectomy
----No T2DM---No GERDNot Gastric bypass mdash anemia smelly flatus
Not OAGBMGB----Anemia Foul smelling flatus and body odor----Protein deficiency
CHOOSING THE BEST BARIATRIC METABOLIC PROCEDURE FOR THE PATIENT
CHOICE OF PROCEDURE
Case 11137 yo Male BMI 68 OSA OA and a non vegetarian who works at your hospitalReferred by the pulmonologist at your medical Centre
Algorithm
OAGBMGBmdashHigh BMI Non Veg-better food tolerance patient very likely to be followedand to afford the supplements because of proximity to your center
Not sleeve---poor weight loss with sleeve in super obeseNot Banded sleeve---Good weight loss but poor food tolerance since patient is a non vegetarianNot Gastric bypass---Weight loss in super obese have high non response after gastric bypass
and the gastric bypass is technically a more difficult operation than the OAGBNot Banded gastric bypass ndashGood weight loss but a BGBP is a more difficult operation and
the patient will have some food intolerance because of the ring
SURGICAL TREATMENT OPTIONS
At Mohak we perform these standard three operations and their banded modifications
Sleeve Gastrectomy Gastric Bypass OAGBMGB
CHOICE OF PROCEDURE
Evidence based operations performed at MBRSC From 2010 t0 2017---Standardized OperationsLaparoscopic Sleeve Gastrectomybull 90-120 cc Sleevebull 2-5cm from pylorusbull Where a sleeve is indicated but a band is contraindicated or not affordableBanded Sleeve Gastrectomy (BSG) 84 EWL after 60 monthsbull 90-120 cc Sleevebull 2-5cm from pylorusbull Ring 65-75 cmbull At 3-6 cm below GE junctionBanded Gastric bypass (BGBP) 75 EWL 48 monthsbull Create 6mdash7cm long pouchbull 65-75 cm ring at 3-5 cm below GE junction and gt2cm above anastomosisbull Large Gastroenterostomy gt 2cm bull 100cm Roux Limb and 80 cm BP limb for BMIlt50bull 100cm Roux Limb and 150 cm BP limb for BMIgt50Mini-Gastric Bypass (MGB) (OAGB) 79 EWL 60 monthsbull 9-18cm long pouch ~25cm widebull BP Limb length of 180cm BMIlt50Banded Mini-Gastric Bypass(BMGB)(BOAGB)bull 9-18cm long pouch ~25cm widebull Ring 7-75 cmbull BP Limb length of 180cm BMI50
THE MOHAK PROTOCOLStandardized Bariatric and Robotic Surgery Operations
CHOICE OF PROCEDURE
Sleeve Gastrectomy (LSG) or Banded Sleeve Gastrectomy (BSG)bull Non-diabeticsbull No hiatal hernia or GERDbull HO Smokingbull HO alcohol usebull HO PUDbull Abnormal LFTs NASH and early Cirrhosisbull Pts from areas with high incidence of gastric cancer of H pylori infectionbull High risks patients and super obese patients as part of a two-staged operation
Gastric Bypass (LGBP) or Banded Gastric Bypass (BGBP) or Hybrid BGBPMGBbull Have T2DM with HgbA1c lt 8 and duration lt 5 yearsbull Have Hiatal hernia or GERDbull Are Vegetarianbull No nicotine addiction (smoking)bull Have HO Alcohol intake bull Have NASH at surgery-No cirrhosisbull Not likely to come back for follow up andbull Revision operation of Failed Sleeve gastrectomy GBP or MGB
MOHAK ALGORITHM
CHOICE OF PROCEDURE
One Anastomosis Gastric Bypass-Mini-Gastric Bypass (OAGBP-MGB) bull Have T2DM with HgbA1c 8 and durationgt5 yearsbull Have No GERDbull Are Non-vegetarianbull Have poor dentitionbull Most likely to return for follow up at the clinicbull No HO alcohol intakebull No Nicotine addiction (smoking)bull Normal LFTsbull No NASH at surgery or cirrhosisbull Commitment by our program to have 100 follow up of theses patient
Revision Operationbull Sleeve to Banded RY with 100 cm Al limb and 180 cm BP Limbbull MGB to diverted MGB for Reflux Existing BPL and 100cm ALbull MGB to GBP for PCM or reversal to normal anatomy for PCMmdashinterim gastrostomy feedingbull GBP to BGBP with 180cm BP limb for Weight regain or inadequate weight loss BMIlt40bull GBP to BGBP with 300cm common limb for Weight regain or inadequate weight loss BMIgt40
MOHAK ALGORITHM
CHOICE OF PROCEDURE
bull Laparoscopic Gastric Bypass
bull Laparoscopic Sleeve Gastrectomy
bull Divided Mini-Gastric Bypass
bull Biliopancreatic Diversion with DS
bull Single Anastomosis Duodeno-ileostomy
bull Gastric Plication
bull Banded Gastric Plication
bull Endoscopic Gastroplasty
bull Laparoscopic Adjustable Gastric bands
bull Balloon Implantation
bull Ileal interposition
These other operations will be used selectively based on patients needs and the surgeons determination
CHOICE OF PROCEDURE
The MOHAK Guide for Choice of Bariatric Metabolic Surgery Operations
Single Incision Laparoscopic Robotic and Endoscopic approaches are
available at patientsrsquo requests and the discretion of the surgeon
CHOICE OF PROCEDURE
The MOHAK Guide for Choice of Bariatric Metabolic Surgery Operations
Mohak Bariatrics and Robotics Surgery Center Motto
ldquoThe best operation for the patient by a competent surgeon in a well equipped hospital to maximize outcomes with the least amount of risks exposurerdquo
WE ARE ABLE TO CHOOSE THE BEST BARIATRIC METABOLIC PROCEDURE FOR YOUR PATIENT
Good long-term results are our marketing toolSuccessful patients make a lot of referralsbull
CHOICE OF PROCEDURE
The MOHAK Guide for Choice of Bariatric Metabolic Surgery Operations
We offer various treatment modalities for obesity The operation is
determined by the profile of the patient and guided by findings from
analysis of the data from our prospectively maintained database
MOHAK TEAM INDORE INDIA
THANK YOU
Sleeve gastrectomy with duodenal bypass(SGDJB) in patients with indication for Gastric Bypass in Gastric Cancer Endemic Areas
As effective as GBPSame weight loss andmetabolic effects as gastric bypass
SG-DJB
CHOICE OF PROCEDURE
ALGORITHM
Sleeve gastrectomy with duodenal bypass(SGDJB) in patients
1Second stage operation for the sleeve gastrectomy
2 Non responders or complications of sleeve gastric bypass or OAGBMGB
BPD-DS SADI SASI SG with enteral bypass
CHOICE OF PROCEDURE
ALGORITHM
BPD-DS SADI SAGI SASI) Indicated for
Areas with high incidence of anemia and very strict vegetarian food habits
CHOICE OF PROCEDURE
ALGORITHM
Sleeve Gastrectomy with gastro-jejunal gastro-ileal or entero-enteral anastomosis
Intra Gastric Balloon ENDOBARRIER
V-BLOC Aspire AssistEndoscopic Plication
For a patient who does not want an intra abdominal gastro-intestinal procedure
CHOICE OF PROCEDURE
Should You Do A Bariatric Metabolic Operation Because That Is What The Patient Wantsrdquo
NOYESmdashIt depends HoweverA bariatric metabolic surgeon should be able to offer the best operation for the patient based on the patientrsquos profile It is good practice to refer the patient to a tertiary center if the surgeon does not offer the operation that meets the patients indication
CHOICE OF PROCEDURE
CHOOSING THE BEST BARIATRIC METABOLIC PROCEDURE FOR THE PATIENT
CHOICE OF PROCEDURE
Case 157 yo Male BMI 57KgM2 T2DM GERD Strict Vegetarian
Algorithm
Gastric bypass-----Preferably Banded gastric bypassmdash------GERD Vegetarian
Not Sleeve because of T2DM GERD and High BMI
Not OAGBMGB because of GERD and probable of protein deficiency
CHOOSING THE BEST BARIATRIC METABOLIC PROCEDURE FOR THE PATIENT
CHOICE OF PROCEDURE
Case 1128 y0 F BMI 42 PCO DUB OSA and HO Migraine headaches
AlgorithmSleeve GastrectomymdashPreferably a Ring banded Sleeve gastrectomy
----No T2DM---No GERDNot Gastric bypass mdash anemia smelly flatus
Not OAGBMGB----Anemia Foul smelling flatus and body odor----Protein deficiency
CHOOSING THE BEST BARIATRIC METABOLIC PROCEDURE FOR THE PATIENT
CHOICE OF PROCEDURE
Case 11137 yo Male BMI 68 OSA OA and a non vegetarian who works at your hospitalReferred by the pulmonologist at your medical Centre
Algorithm
OAGBMGBmdashHigh BMI Non Veg-better food tolerance patient very likely to be followedand to afford the supplements because of proximity to your center
Not sleeve---poor weight loss with sleeve in super obeseNot Banded sleeve---Good weight loss but poor food tolerance since patient is a non vegetarianNot Gastric bypass---Weight loss in super obese have high non response after gastric bypass
and the gastric bypass is technically a more difficult operation than the OAGBNot Banded gastric bypass ndashGood weight loss but a BGBP is a more difficult operation and
the patient will have some food intolerance because of the ring
SURGICAL TREATMENT OPTIONS
At Mohak we perform these standard three operations and their banded modifications
Sleeve Gastrectomy Gastric Bypass OAGBMGB
CHOICE OF PROCEDURE
Evidence based operations performed at MBRSC From 2010 t0 2017---Standardized OperationsLaparoscopic Sleeve Gastrectomybull 90-120 cc Sleevebull 2-5cm from pylorusbull Where a sleeve is indicated but a band is contraindicated or not affordableBanded Sleeve Gastrectomy (BSG) 84 EWL after 60 monthsbull 90-120 cc Sleevebull 2-5cm from pylorusbull Ring 65-75 cmbull At 3-6 cm below GE junctionBanded Gastric bypass (BGBP) 75 EWL 48 monthsbull Create 6mdash7cm long pouchbull 65-75 cm ring at 3-5 cm below GE junction and gt2cm above anastomosisbull Large Gastroenterostomy gt 2cm bull 100cm Roux Limb and 80 cm BP limb for BMIlt50bull 100cm Roux Limb and 150 cm BP limb for BMIgt50Mini-Gastric Bypass (MGB) (OAGB) 79 EWL 60 monthsbull 9-18cm long pouch ~25cm widebull BP Limb length of 180cm BMIlt50Banded Mini-Gastric Bypass(BMGB)(BOAGB)bull 9-18cm long pouch ~25cm widebull Ring 7-75 cmbull BP Limb length of 180cm BMI50
THE MOHAK PROTOCOLStandardized Bariatric and Robotic Surgery Operations
CHOICE OF PROCEDURE
Sleeve Gastrectomy (LSG) or Banded Sleeve Gastrectomy (BSG)bull Non-diabeticsbull No hiatal hernia or GERDbull HO Smokingbull HO alcohol usebull HO PUDbull Abnormal LFTs NASH and early Cirrhosisbull Pts from areas with high incidence of gastric cancer of H pylori infectionbull High risks patients and super obese patients as part of a two-staged operation
Gastric Bypass (LGBP) or Banded Gastric Bypass (BGBP) or Hybrid BGBPMGBbull Have T2DM with HgbA1c lt 8 and duration lt 5 yearsbull Have Hiatal hernia or GERDbull Are Vegetarianbull No nicotine addiction (smoking)bull Have HO Alcohol intake bull Have NASH at surgery-No cirrhosisbull Not likely to come back for follow up andbull Revision operation of Failed Sleeve gastrectomy GBP or MGB
MOHAK ALGORITHM
CHOICE OF PROCEDURE
One Anastomosis Gastric Bypass-Mini-Gastric Bypass (OAGBP-MGB) bull Have T2DM with HgbA1c 8 and durationgt5 yearsbull Have No GERDbull Are Non-vegetarianbull Have poor dentitionbull Most likely to return for follow up at the clinicbull No HO alcohol intakebull No Nicotine addiction (smoking)bull Normal LFTsbull No NASH at surgery or cirrhosisbull Commitment by our program to have 100 follow up of theses patient
Revision Operationbull Sleeve to Banded RY with 100 cm Al limb and 180 cm BP Limbbull MGB to diverted MGB for Reflux Existing BPL and 100cm ALbull MGB to GBP for PCM or reversal to normal anatomy for PCMmdashinterim gastrostomy feedingbull GBP to BGBP with 180cm BP limb for Weight regain or inadequate weight loss BMIlt40bull GBP to BGBP with 300cm common limb for Weight regain or inadequate weight loss BMIgt40
MOHAK ALGORITHM
CHOICE OF PROCEDURE
bull Laparoscopic Gastric Bypass
bull Laparoscopic Sleeve Gastrectomy
bull Divided Mini-Gastric Bypass
bull Biliopancreatic Diversion with DS
bull Single Anastomosis Duodeno-ileostomy
bull Gastric Plication
bull Banded Gastric Plication
bull Endoscopic Gastroplasty
bull Laparoscopic Adjustable Gastric bands
bull Balloon Implantation
bull Ileal interposition
These other operations will be used selectively based on patients needs and the surgeons determination
CHOICE OF PROCEDURE
The MOHAK Guide for Choice of Bariatric Metabolic Surgery Operations
Single Incision Laparoscopic Robotic and Endoscopic approaches are
available at patientsrsquo requests and the discretion of the surgeon
CHOICE OF PROCEDURE
The MOHAK Guide for Choice of Bariatric Metabolic Surgery Operations
Mohak Bariatrics and Robotics Surgery Center Motto
ldquoThe best operation for the patient by a competent surgeon in a well equipped hospital to maximize outcomes with the least amount of risks exposurerdquo
WE ARE ABLE TO CHOOSE THE BEST BARIATRIC METABOLIC PROCEDURE FOR YOUR PATIENT
Good long-term results are our marketing toolSuccessful patients make a lot of referralsbull
CHOICE OF PROCEDURE
The MOHAK Guide for Choice of Bariatric Metabolic Surgery Operations
We offer various treatment modalities for obesity The operation is
determined by the profile of the patient and guided by findings from
analysis of the data from our prospectively maintained database
MOHAK TEAM INDORE INDIA
THANK YOU
1Second stage operation for the sleeve gastrectomy
2 Non responders or complications of sleeve gastric bypass or OAGBMGB
BPD-DS SADI SASI SG with enteral bypass
CHOICE OF PROCEDURE
ALGORITHM
BPD-DS SADI SAGI SASI) Indicated for
Areas with high incidence of anemia and very strict vegetarian food habits
CHOICE OF PROCEDURE
ALGORITHM
Sleeve Gastrectomy with gastro-jejunal gastro-ileal or entero-enteral anastomosis
Intra Gastric Balloon ENDOBARRIER
V-BLOC Aspire AssistEndoscopic Plication
For a patient who does not want an intra abdominal gastro-intestinal procedure
CHOICE OF PROCEDURE
Should You Do A Bariatric Metabolic Operation Because That Is What The Patient Wantsrdquo
NOYESmdashIt depends HoweverA bariatric metabolic surgeon should be able to offer the best operation for the patient based on the patientrsquos profile It is good practice to refer the patient to a tertiary center if the surgeon does not offer the operation that meets the patients indication
CHOICE OF PROCEDURE
CHOOSING THE BEST BARIATRIC METABOLIC PROCEDURE FOR THE PATIENT
CHOICE OF PROCEDURE
Case 157 yo Male BMI 57KgM2 T2DM GERD Strict Vegetarian
Algorithm
Gastric bypass-----Preferably Banded gastric bypassmdash------GERD Vegetarian
Not Sleeve because of T2DM GERD and High BMI
Not OAGBMGB because of GERD and probable of protein deficiency
CHOOSING THE BEST BARIATRIC METABOLIC PROCEDURE FOR THE PATIENT
CHOICE OF PROCEDURE
Case 1128 y0 F BMI 42 PCO DUB OSA and HO Migraine headaches
AlgorithmSleeve GastrectomymdashPreferably a Ring banded Sleeve gastrectomy
----No T2DM---No GERDNot Gastric bypass mdash anemia smelly flatus
Not OAGBMGB----Anemia Foul smelling flatus and body odor----Protein deficiency
CHOOSING THE BEST BARIATRIC METABOLIC PROCEDURE FOR THE PATIENT
CHOICE OF PROCEDURE
Case 11137 yo Male BMI 68 OSA OA and a non vegetarian who works at your hospitalReferred by the pulmonologist at your medical Centre
Algorithm
OAGBMGBmdashHigh BMI Non Veg-better food tolerance patient very likely to be followedand to afford the supplements because of proximity to your center
Not sleeve---poor weight loss with sleeve in super obeseNot Banded sleeve---Good weight loss but poor food tolerance since patient is a non vegetarianNot Gastric bypass---Weight loss in super obese have high non response after gastric bypass
and the gastric bypass is technically a more difficult operation than the OAGBNot Banded gastric bypass ndashGood weight loss but a BGBP is a more difficult operation and
the patient will have some food intolerance because of the ring
SURGICAL TREATMENT OPTIONS
At Mohak we perform these standard three operations and their banded modifications
Sleeve Gastrectomy Gastric Bypass OAGBMGB
CHOICE OF PROCEDURE
Evidence based operations performed at MBRSC From 2010 t0 2017---Standardized OperationsLaparoscopic Sleeve Gastrectomybull 90-120 cc Sleevebull 2-5cm from pylorusbull Where a sleeve is indicated but a band is contraindicated or not affordableBanded Sleeve Gastrectomy (BSG) 84 EWL after 60 monthsbull 90-120 cc Sleevebull 2-5cm from pylorusbull Ring 65-75 cmbull At 3-6 cm below GE junctionBanded Gastric bypass (BGBP) 75 EWL 48 monthsbull Create 6mdash7cm long pouchbull 65-75 cm ring at 3-5 cm below GE junction and gt2cm above anastomosisbull Large Gastroenterostomy gt 2cm bull 100cm Roux Limb and 80 cm BP limb for BMIlt50bull 100cm Roux Limb and 150 cm BP limb for BMIgt50Mini-Gastric Bypass (MGB) (OAGB) 79 EWL 60 monthsbull 9-18cm long pouch ~25cm widebull BP Limb length of 180cm BMIlt50Banded Mini-Gastric Bypass(BMGB)(BOAGB)bull 9-18cm long pouch ~25cm widebull Ring 7-75 cmbull BP Limb length of 180cm BMI50
THE MOHAK PROTOCOLStandardized Bariatric and Robotic Surgery Operations
CHOICE OF PROCEDURE
Sleeve Gastrectomy (LSG) or Banded Sleeve Gastrectomy (BSG)bull Non-diabeticsbull No hiatal hernia or GERDbull HO Smokingbull HO alcohol usebull HO PUDbull Abnormal LFTs NASH and early Cirrhosisbull Pts from areas with high incidence of gastric cancer of H pylori infectionbull High risks patients and super obese patients as part of a two-staged operation
Gastric Bypass (LGBP) or Banded Gastric Bypass (BGBP) or Hybrid BGBPMGBbull Have T2DM with HgbA1c lt 8 and duration lt 5 yearsbull Have Hiatal hernia or GERDbull Are Vegetarianbull No nicotine addiction (smoking)bull Have HO Alcohol intake bull Have NASH at surgery-No cirrhosisbull Not likely to come back for follow up andbull Revision operation of Failed Sleeve gastrectomy GBP or MGB
MOHAK ALGORITHM
CHOICE OF PROCEDURE
One Anastomosis Gastric Bypass-Mini-Gastric Bypass (OAGBP-MGB) bull Have T2DM with HgbA1c 8 and durationgt5 yearsbull Have No GERDbull Are Non-vegetarianbull Have poor dentitionbull Most likely to return for follow up at the clinicbull No HO alcohol intakebull No Nicotine addiction (smoking)bull Normal LFTsbull No NASH at surgery or cirrhosisbull Commitment by our program to have 100 follow up of theses patient
Revision Operationbull Sleeve to Banded RY with 100 cm Al limb and 180 cm BP Limbbull MGB to diverted MGB for Reflux Existing BPL and 100cm ALbull MGB to GBP for PCM or reversal to normal anatomy for PCMmdashinterim gastrostomy feedingbull GBP to BGBP with 180cm BP limb for Weight regain or inadequate weight loss BMIlt40bull GBP to BGBP with 300cm common limb for Weight regain or inadequate weight loss BMIgt40
MOHAK ALGORITHM
CHOICE OF PROCEDURE
bull Laparoscopic Gastric Bypass
bull Laparoscopic Sleeve Gastrectomy
bull Divided Mini-Gastric Bypass
bull Biliopancreatic Diversion with DS
bull Single Anastomosis Duodeno-ileostomy
bull Gastric Plication
bull Banded Gastric Plication
bull Endoscopic Gastroplasty
bull Laparoscopic Adjustable Gastric bands
bull Balloon Implantation
bull Ileal interposition
These other operations will be used selectively based on patients needs and the surgeons determination
CHOICE OF PROCEDURE
The MOHAK Guide for Choice of Bariatric Metabolic Surgery Operations
Single Incision Laparoscopic Robotic and Endoscopic approaches are
available at patientsrsquo requests and the discretion of the surgeon
CHOICE OF PROCEDURE
The MOHAK Guide for Choice of Bariatric Metabolic Surgery Operations
Mohak Bariatrics and Robotics Surgery Center Motto
ldquoThe best operation for the patient by a competent surgeon in a well equipped hospital to maximize outcomes with the least amount of risks exposurerdquo
WE ARE ABLE TO CHOOSE THE BEST BARIATRIC METABOLIC PROCEDURE FOR YOUR PATIENT
Good long-term results are our marketing toolSuccessful patients make a lot of referralsbull
CHOICE OF PROCEDURE
The MOHAK Guide for Choice of Bariatric Metabolic Surgery Operations
We offer various treatment modalities for obesity The operation is
determined by the profile of the patient and guided by findings from
analysis of the data from our prospectively maintained database
MOHAK TEAM INDORE INDIA
THANK YOU
Areas with high incidence of anemia and very strict vegetarian food habits
CHOICE OF PROCEDURE
ALGORITHM
Sleeve Gastrectomy with gastro-jejunal gastro-ileal or entero-enteral anastomosis
Intra Gastric Balloon ENDOBARRIER
V-BLOC Aspire AssistEndoscopic Plication
For a patient who does not want an intra abdominal gastro-intestinal procedure
CHOICE OF PROCEDURE
Should You Do A Bariatric Metabolic Operation Because That Is What The Patient Wantsrdquo
NOYESmdashIt depends HoweverA bariatric metabolic surgeon should be able to offer the best operation for the patient based on the patientrsquos profile It is good practice to refer the patient to a tertiary center if the surgeon does not offer the operation that meets the patients indication
CHOICE OF PROCEDURE
CHOOSING THE BEST BARIATRIC METABOLIC PROCEDURE FOR THE PATIENT
CHOICE OF PROCEDURE
Case 157 yo Male BMI 57KgM2 T2DM GERD Strict Vegetarian
Algorithm
Gastric bypass-----Preferably Banded gastric bypassmdash------GERD Vegetarian
Not Sleeve because of T2DM GERD and High BMI
Not OAGBMGB because of GERD and probable of protein deficiency
CHOOSING THE BEST BARIATRIC METABOLIC PROCEDURE FOR THE PATIENT
CHOICE OF PROCEDURE
Case 1128 y0 F BMI 42 PCO DUB OSA and HO Migraine headaches
AlgorithmSleeve GastrectomymdashPreferably a Ring banded Sleeve gastrectomy
----No T2DM---No GERDNot Gastric bypass mdash anemia smelly flatus
Not OAGBMGB----Anemia Foul smelling flatus and body odor----Protein deficiency
CHOOSING THE BEST BARIATRIC METABOLIC PROCEDURE FOR THE PATIENT
CHOICE OF PROCEDURE
Case 11137 yo Male BMI 68 OSA OA and a non vegetarian who works at your hospitalReferred by the pulmonologist at your medical Centre
Algorithm
OAGBMGBmdashHigh BMI Non Veg-better food tolerance patient very likely to be followedand to afford the supplements because of proximity to your center
Not sleeve---poor weight loss with sleeve in super obeseNot Banded sleeve---Good weight loss but poor food tolerance since patient is a non vegetarianNot Gastric bypass---Weight loss in super obese have high non response after gastric bypass
and the gastric bypass is technically a more difficult operation than the OAGBNot Banded gastric bypass ndashGood weight loss but a BGBP is a more difficult operation and
the patient will have some food intolerance because of the ring
SURGICAL TREATMENT OPTIONS
At Mohak we perform these standard three operations and their banded modifications
Sleeve Gastrectomy Gastric Bypass OAGBMGB
CHOICE OF PROCEDURE
Evidence based operations performed at MBRSC From 2010 t0 2017---Standardized OperationsLaparoscopic Sleeve Gastrectomybull 90-120 cc Sleevebull 2-5cm from pylorusbull Where a sleeve is indicated but a band is contraindicated or not affordableBanded Sleeve Gastrectomy (BSG) 84 EWL after 60 monthsbull 90-120 cc Sleevebull 2-5cm from pylorusbull Ring 65-75 cmbull At 3-6 cm below GE junctionBanded Gastric bypass (BGBP) 75 EWL 48 monthsbull Create 6mdash7cm long pouchbull 65-75 cm ring at 3-5 cm below GE junction and gt2cm above anastomosisbull Large Gastroenterostomy gt 2cm bull 100cm Roux Limb and 80 cm BP limb for BMIlt50bull 100cm Roux Limb and 150 cm BP limb for BMIgt50Mini-Gastric Bypass (MGB) (OAGB) 79 EWL 60 monthsbull 9-18cm long pouch ~25cm widebull BP Limb length of 180cm BMIlt50Banded Mini-Gastric Bypass(BMGB)(BOAGB)bull 9-18cm long pouch ~25cm widebull Ring 7-75 cmbull BP Limb length of 180cm BMI50
THE MOHAK PROTOCOLStandardized Bariatric and Robotic Surgery Operations
CHOICE OF PROCEDURE
Sleeve Gastrectomy (LSG) or Banded Sleeve Gastrectomy (BSG)bull Non-diabeticsbull No hiatal hernia or GERDbull HO Smokingbull HO alcohol usebull HO PUDbull Abnormal LFTs NASH and early Cirrhosisbull Pts from areas with high incidence of gastric cancer of H pylori infectionbull High risks patients and super obese patients as part of a two-staged operation
Gastric Bypass (LGBP) or Banded Gastric Bypass (BGBP) or Hybrid BGBPMGBbull Have T2DM with HgbA1c lt 8 and duration lt 5 yearsbull Have Hiatal hernia or GERDbull Are Vegetarianbull No nicotine addiction (smoking)bull Have HO Alcohol intake bull Have NASH at surgery-No cirrhosisbull Not likely to come back for follow up andbull Revision operation of Failed Sleeve gastrectomy GBP or MGB
MOHAK ALGORITHM
CHOICE OF PROCEDURE
One Anastomosis Gastric Bypass-Mini-Gastric Bypass (OAGBP-MGB) bull Have T2DM with HgbA1c 8 and durationgt5 yearsbull Have No GERDbull Are Non-vegetarianbull Have poor dentitionbull Most likely to return for follow up at the clinicbull No HO alcohol intakebull No Nicotine addiction (smoking)bull Normal LFTsbull No NASH at surgery or cirrhosisbull Commitment by our program to have 100 follow up of theses patient
Revision Operationbull Sleeve to Banded RY with 100 cm Al limb and 180 cm BP Limbbull MGB to diverted MGB for Reflux Existing BPL and 100cm ALbull MGB to GBP for PCM or reversal to normal anatomy for PCMmdashinterim gastrostomy feedingbull GBP to BGBP with 180cm BP limb for Weight regain or inadequate weight loss BMIlt40bull GBP to BGBP with 300cm common limb for Weight regain or inadequate weight loss BMIgt40
MOHAK ALGORITHM
CHOICE OF PROCEDURE
bull Laparoscopic Gastric Bypass
bull Laparoscopic Sleeve Gastrectomy
bull Divided Mini-Gastric Bypass
bull Biliopancreatic Diversion with DS
bull Single Anastomosis Duodeno-ileostomy
bull Gastric Plication
bull Banded Gastric Plication
bull Endoscopic Gastroplasty
bull Laparoscopic Adjustable Gastric bands
bull Balloon Implantation
bull Ileal interposition
These other operations will be used selectively based on patients needs and the surgeons determination
CHOICE OF PROCEDURE
The MOHAK Guide for Choice of Bariatric Metabolic Surgery Operations
Single Incision Laparoscopic Robotic and Endoscopic approaches are
available at patientsrsquo requests and the discretion of the surgeon
CHOICE OF PROCEDURE
The MOHAK Guide for Choice of Bariatric Metabolic Surgery Operations
Mohak Bariatrics and Robotics Surgery Center Motto
ldquoThe best operation for the patient by a competent surgeon in a well equipped hospital to maximize outcomes with the least amount of risks exposurerdquo
WE ARE ABLE TO CHOOSE THE BEST BARIATRIC METABOLIC PROCEDURE FOR YOUR PATIENT
Good long-term results are our marketing toolSuccessful patients make a lot of referralsbull
CHOICE OF PROCEDURE
The MOHAK Guide for Choice of Bariatric Metabolic Surgery Operations
We offer various treatment modalities for obesity The operation is
determined by the profile of the patient and guided by findings from
analysis of the data from our prospectively maintained database
MOHAK TEAM INDORE INDIA
THANK YOU
Intra Gastric Balloon ENDOBARRIER
V-BLOC Aspire AssistEndoscopic Plication
For a patient who does not want an intra abdominal gastro-intestinal procedure
CHOICE OF PROCEDURE
Should You Do A Bariatric Metabolic Operation Because That Is What The Patient Wantsrdquo
NOYESmdashIt depends HoweverA bariatric metabolic surgeon should be able to offer the best operation for the patient based on the patientrsquos profile It is good practice to refer the patient to a tertiary center if the surgeon does not offer the operation that meets the patients indication
CHOICE OF PROCEDURE
CHOOSING THE BEST BARIATRIC METABOLIC PROCEDURE FOR THE PATIENT
CHOICE OF PROCEDURE
Case 157 yo Male BMI 57KgM2 T2DM GERD Strict Vegetarian
Algorithm
Gastric bypass-----Preferably Banded gastric bypassmdash------GERD Vegetarian
Not Sleeve because of T2DM GERD and High BMI
Not OAGBMGB because of GERD and probable of protein deficiency
CHOOSING THE BEST BARIATRIC METABOLIC PROCEDURE FOR THE PATIENT
CHOICE OF PROCEDURE
Case 1128 y0 F BMI 42 PCO DUB OSA and HO Migraine headaches
AlgorithmSleeve GastrectomymdashPreferably a Ring banded Sleeve gastrectomy
----No T2DM---No GERDNot Gastric bypass mdash anemia smelly flatus
Not OAGBMGB----Anemia Foul smelling flatus and body odor----Protein deficiency
CHOOSING THE BEST BARIATRIC METABOLIC PROCEDURE FOR THE PATIENT
CHOICE OF PROCEDURE
Case 11137 yo Male BMI 68 OSA OA and a non vegetarian who works at your hospitalReferred by the pulmonologist at your medical Centre
Algorithm
OAGBMGBmdashHigh BMI Non Veg-better food tolerance patient very likely to be followedand to afford the supplements because of proximity to your center
Not sleeve---poor weight loss with sleeve in super obeseNot Banded sleeve---Good weight loss but poor food tolerance since patient is a non vegetarianNot Gastric bypass---Weight loss in super obese have high non response after gastric bypass
and the gastric bypass is technically a more difficult operation than the OAGBNot Banded gastric bypass ndashGood weight loss but a BGBP is a more difficult operation and
the patient will have some food intolerance because of the ring
SURGICAL TREATMENT OPTIONS
At Mohak we perform these standard three operations and their banded modifications
Sleeve Gastrectomy Gastric Bypass OAGBMGB
CHOICE OF PROCEDURE
Evidence based operations performed at MBRSC From 2010 t0 2017---Standardized OperationsLaparoscopic Sleeve Gastrectomybull 90-120 cc Sleevebull 2-5cm from pylorusbull Where a sleeve is indicated but a band is contraindicated or not affordableBanded Sleeve Gastrectomy (BSG) 84 EWL after 60 monthsbull 90-120 cc Sleevebull 2-5cm from pylorusbull Ring 65-75 cmbull At 3-6 cm below GE junctionBanded Gastric bypass (BGBP) 75 EWL 48 monthsbull Create 6mdash7cm long pouchbull 65-75 cm ring at 3-5 cm below GE junction and gt2cm above anastomosisbull Large Gastroenterostomy gt 2cm bull 100cm Roux Limb and 80 cm BP limb for BMIlt50bull 100cm Roux Limb and 150 cm BP limb for BMIgt50Mini-Gastric Bypass (MGB) (OAGB) 79 EWL 60 monthsbull 9-18cm long pouch ~25cm widebull BP Limb length of 180cm BMIlt50Banded Mini-Gastric Bypass(BMGB)(BOAGB)bull 9-18cm long pouch ~25cm widebull Ring 7-75 cmbull BP Limb length of 180cm BMI50
THE MOHAK PROTOCOLStandardized Bariatric and Robotic Surgery Operations
CHOICE OF PROCEDURE
Sleeve Gastrectomy (LSG) or Banded Sleeve Gastrectomy (BSG)bull Non-diabeticsbull No hiatal hernia or GERDbull HO Smokingbull HO alcohol usebull HO PUDbull Abnormal LFTs NASH and early Cirrhosisbull Pts from areas with high incidence of gastric cancer of H pylori infectionbull High risks patients and super obese patients as part of a two-staged operation
Gastric Bypass (LGBP) or Banded Gastric Bypass (BGBP) or Hybrid BGBPMGBbull Have T2DM with HgbA1c lt 8 and duration lt 5 yearsbull Have Hiatal hernia or GERDbull Are Vegetarianbull No nicotine addiction (smoking)bull Have HO Alcohol intake bull Have NASH at surgery-No cirrhosisbull Not likely to come back for follow up andbull Revision operation of Failed Sleeve gastrectomy GBP or MGB
MOHAK ALGORITHM
CHOICE OF PROCEDURE
One Anastomosis Gastric Bypass-Mini-Gastric Bypass (OAGBP-MGB) bull Have T2DM with HgbA1c 8 and durationgt5 yearsbull Have No GERDbull Are Non-vegetarianbull Have poor dentitionbull Most likely to return for follow up at the clinicbull No HO alcohol intakebull No Nicotine addiction (smoking)bull Normal LFTsbull No NASH at surgery or cirrhosisbull Commitment by our program to have 100 follow up of theses patient
Revision Operationbull Sleeve to Banded RY with 100 cm Al limb and 180 cm BP Limbbull MGB to diverted MGB for Reflux Existing BPL and 100cm ALbull MGB to GBP for PCM or reversal to normal anatomy for PCMmdashinterim gastrostomy feedingbull GBP to BGBP with 180cm BP limb for Weight regain or inadequate weight loss BMIlt40bull GBP to BGBP with 300cm common limb for Weight regain or inadequate weight loss BMIgt40
MOHAK ALGORITHM
CHOICE OF PROCEDURE
bull Laparoscopic Gastric Bypass
bull Laparoscopic Sleeve Gastrectomy
bull Divided Mini-Gastric Bypass
bull Biliopancreatic Diversion with DS
bull Single Anastomosis Duodeno-ileostomy
bull Gastric Plication
bull Banded Gastric Plication
bull Endoscopic Gastroplasty
bull Laparoscopic Adjustable Gastric bands
bull Balloon Implantation
bull Ileal interposition
These other operations will be used selectively based on patients needs and the surgeons determination
CHOICE OF PROCEDURE
The MOHAK Guide for Choice of Bariatric Metabolic Surgery Operations
Single Incision Laparoscopic Robotic and Endoscopic approaches are
available at patientsrsquo requests and the discretion of the surgeon
CHOICE OF PROCEDURE
The MOHAK Guide for Choice of Bariatric Metabolic Surgery Operations
Mohak Bariatrics and Robotics Surgery Center Motto
ldquoThe best operation for the patient by a competent surgeon in a well equipped hospital to maximize outcomes with the least amount of risks exposurerdquo
WE ARE ABLE TO CHOOSE THE BEST BARIATRIC METABOLIC PROCEDURE FOR YOUR PATIENT
Good long-term results are our marketing toolSuccessful patients make a lot of referralsbull
CHOICE OF PROCEDURE
The MOHAK Guide for Choice of Bariatric Metabolic Surgery Operations
We offer various treatment modalities for obesity The operation is
determined by the profile of the patient and guided by findings from
analysis of the data from our prospectively maintained database
MOHAK TEAM INDORE INDIA
THANK YOU
Should You Do A Bariatric Metabolic Operation Because That Is What The Patient Wantsrdquo
NOYESmdashIt depends HoweverA bariatric metabolic surgeon should be able to offer the best operation for the patient based on the patientrsquos profile It is good practice to refer the patient to a tertiary center if the surgeon does not offer the operation that meets the patients indication
CHOICE OF PROCEDURE
CHOOSING THE BEST BARIATRIC METABOLIC PROCEDURE FOR THE PATIENT
CHOICE OF PROCEDURE
Case 157 yo Male BMI 57KgM2 T2DM GERD Strict Vegetarian
Algorithm
Gastric bypass-----Preferably Banded gastric bypassmdash------GERD Vegetarian
Not Sleeve because of T2DM GERD and High BMI
Not OAGBMGB because of GERD and probable of protein deficiency
CHOOSING THE BEST BARIATRIC METABOLIC PROCEDURE FOR THE PATIENT
CHOICE OF PROCEDURE
Case 1128 y0 F BMI 42 PCO DUB OSA and HO Migraine headaches
AlgorithmSleeve GastrectomymdashPreferably a Ring banded Sleeve gastrectomy
----No T2DM---No GERDNot Gastric bypass mdash anemia smelly flatus
Not OAGBMGB----Anemia Foul smelling flatus and body odor----Protein deficiency
CHOOSING THE BEST BARIATRIC METABOLIC PROCEDURE FOR THE PATIENT
CHOICE OF PROCEDURE
Case 11137 yo Male BMI 68 OSA OA and a non vegetarian who works at your hospitalReferred by the pulmonologist at your medical Centre
Algorithm
OAGBMGBmdashHigh BMI Non Veg-better food tolerance patient very likely to be followedand to afford the supplements because of proximity to your center
Not sleeve---poor weight loss with sleeve in super obeseNot Banded sleeve---Good weight loss but poor food tolerance since patient is a non vegetarianNot Gastric bypass---Weight loss in super obese have high non response after gastric bypass
and the gastric bypass is technically a more difficult operation than the OAGBNot Banded gastric bypass ndashGood weight loss but a BGBP is a more difficult operation and
the patient will have some food intolerance because of the ring
SURGICAL TREATMENT OPTIONS
At Mohak we perform these standard three operations and their banded modifications
Sleeve Gastrectomy Gastric Bypass OAGBMGB
CHOICE OF PROCEDURE
Evidence based operations performed at MBRSC From 2010 t0 2017---Standardized OperationsLaparoscopic Sleeve Gastrectomybull 90-120 cc Sleevebull 2-5cm from pylorusbull Where a sleeve is indicated but a band is contraindicated or not affordableBanded Sleeve Gastrectomy (BSG) 84 EWL after 60 monthsbull 90-120 cc Sleevebull 2-5cm from pylorusbull Ring 65-75 cmbull At 3-6 cm below GE junctionBanded Gastric bypass (BGBP) 75 EWL 48 monthsbull Create 6mdash7cm long pouchbull 65-75 cm ring at 3-5 cm below GE junction and gt2cm above anastomosisbull Large Gastroenterostomy gt 2cm bull 100cm Roux Limb and 80 cm BP limb for BMIlt50bull 100cm Roux Limb and 150 cm BP limb for BMIgt50Mini-Gastric Bypass (MGB) (OAGB) 79 EWL 60 monthsbull 9-18cm long pouch ~25cm widebull BP Limb length of 180cm BMIlt50Banded Mini-Gastric Bypass(BMGB)(BOAGB)bull 9-18cm long pouch ~25cm widebull Ring 7-75 cmbull BP Limb length of 180cm BMI50
THE MOHAK PROTOCOLStandardized Bariatric and Robotic Surgery Operations
CHOICE OF PROCEDURE
Sleeve Gastrectomy (LSG) or Banded Sleeve Gastrectomy (BSG)bull Non-diabeticsbull No hiatal hernia or GERDbull HO Smokingbull HO alcohol usebull HO PUDbull Abnormal LFTs NASH and early Cirrhosisbull Pts from areas with high incidence of gastric cancer of H pylori infectionbull High risks patients and super obese patients as part of a two-staged operation
Gastric Bypass (LGBP) or Banded Gastric Bypass (BGBP) or Hybrid BGBPMGBbull Have T2DM with HgbA1c lt 8 and duration lt 5 yearsbull Have Hiatal hernia or GERDbull Are Vegetarianbull No nicotine addiction (smoking)bull Have HO Alcohol intake bull Have NASH at surgery-No cirrhosisbull Not likely to come back for follow up andbull Revision operation of Failed Sleeve gastrectomy GBP or MGB
MOHAK ALGORITHM
CHOICE OF PROCEDURE
One Anastomosis Gastric Bypass-Mini-Gastric Bypass (OAGBP-MGB) bull Have T2DM with HgbA1c 8 and durationgt5 yearsbull Have No GERDbull Are Non-vegetarianbull Have poor dentitionbull Most likely to return for follow up at the clinicbull No HO alcohol intakebull No Nicotine addiction (smoking)bull Normal LFTsbull No NASH at surgery or cirrhosisbull Commitment by our program to have 100 follow up of theses patient
Revision Operationbull Sleeve to Banded RY with 100 cm Al limb and 180 cm BP Limbbull MGB to diverted MGB for Reflux Existing BPL and 100cm ALbull MGB to GBP for PCM or reversal to normal anatomy for PCMmdashinterim gastrostomy feedingbull GBP to BGBP with 180cm BP limb for Weight regain or inadequate weight loss BMIlt40bull GBP to BGBP with 300cm common limb for Weight regain or inadequate weight loss BMIgt40
MOHAK ALGORITHM
CHOICE OF PROCEDURE
bull Laparoscopic Gastric Bypass
bull Laparoscopic Sleeve Gastrectomy
bull Divided Mini-Gastric Bypass
bull Biliopancreatic Diversion with DS
bull Single Anastomosis Duodeno-ileostomy
bull Gastric Plication
bull Banded Gastric Plication
bull Endoscopic Gastroplasty
bull Laparoscopic Adjustable Gastric bands
bull Balloon Implantation
bull Ileal interposition
These other operations will be used selectively based on patients needs and the surgeons determination
CHOICE OF PROCEDURE
The MOHAK Guide for Choice of Bariatric Metabolic Surgery Operations
Single Incision Laparoscopic Robotic and Endoscopic approaches are
available at patientsrsquo requests and the discretion of the surgeon
CHOICE OF PROCEDURE
The MOHAK Guide for Choice of Bariatric Metabolic Surgery Operations
Mohak Bariatrics and Robotics Surgery Center Motto
ldquoThe best operation for the patient by a competent surgeon in a well equipped hospital to maximize outcomes with the least amount of risks exposurerdquo
WE ARE ABLE TO CHOOSE THE BEST BARIATRIC METABOLIC PROCEDURE FOR YOUR PATIENT
Good long-term results are our marketing toolSuccessful patients make a lot of referralsbull
CHOICE OF PROCEDURE
The MOHAK Guide for Choice of Bariatric Metabolic Surgery Operations
We offer various treatment modalities for obesity The operation is
determined by the profile of the patient and guided by findings from
analysis of the data from our prospectively maintained database
MOHAK TEAM INDORE INDIA
THANK YOU
CHOOSING THE BEST BARIATRIC METABOLIC PROCEDURE FOR THE PATIENT
CHOICE OF PROCEDURE
Case 157 yo Male BMI 57KgM2 T2DM GERD Strict Vegetarian
Algorithm
Gastric bypass-----Preferably Banded gastric bypassmdash------GERD Vegetarian
Not Sleeve because of T2DM GERD and High BMI
Not OAGBMGB because of GERD and probable of protein deficiency
CHOOSING THE BEST BARIATRIC METABOLIC PROCEDURE FOR THE PATIENT
CHOICE OF PROCEDURE
Case 1128 y0 F BMI 42 PCO DUB OSA and HO Migraine headaches
AlgorithmSleeve GastrectomymdashPreferably a Ring banded Sleeve gastrectomy
----No T2DM---No GERDNot Gastric bypass mdash anemia smelly flatus
Not OAGBMGB----Anemia Foul smelling flatus and body odor----Protein deficiency
CHOOSING THE BEST BARIATRIC METABOLIC PROCEDURE FOR THE PATIENT
CHOICE OF PROCEDURE
Case 11137 yo Male BMI 68 OSA OA and a non vegetarian who works at your hospitalReferred by the pulmonologist at your medical Centre
Algorithm
OAGBMGBmdashHigh BMI Non Veg-better food tolerance patient very likely to be followedand to afford the supplements because of proximity to your center
Not sleeve---poor weight loss with sleeve in super obeseNot Banded sleeve---Good weight loss but poor food tolerance since patient is a non vegetarianNot Gastric bypass---Weight loss in super obese have high non response after gastric bypass
and the gastric bypass is technically a more difficult operation than the OAGBNot Banded gastric bypass ndashGood weight loss but a BGBP is a more difficult operation and
the patient will have some food intolerance because of the ring
SURGICAL TREATMENT OPTIONS
At Mohak we perform these standard three operations and their banded modifications
Sleeve Gastrectomy Gastric Bypass OAGBMGB
CHOICE OF PROCEDURE
Evidence based operations performed at MBRSC From 2010 t0 2017---Standardized OperationsLaparoscopic Sleeve Gastrectomybull 90-120 cc Sleevebull 2-5cm from pylorusbull Where a sleeve is indicated but a band is contraindicated or not affordableBanded Sleeve Gastrectomy (BSG) 84 EWL after 60 monthsbull 90-120 cc Sleevebull 2-5cm from pylorusbull Ring 65-75 cmbull At 3-6 cm below GE junctionBanded Gastric bypass (BGBP) 75 EWL 48 monthsbull Create 6mdash7cm long pouchbull 65-75 cm ring at 3-5 cm below GE junction and gt2cm above anastomosisbull Large Gastroenterostomy gt 2cm bull 100cm Roux Limb and 80 cm BP limb for BMIlt50bull 100cm Roux Limb and 150 cm BP limb for BMIgt50Mini-Gastric Bypass (MGB) (OAGB) 79 EWL 60 monthsbull 9-18cm long pouch ~25cm widebull BP Limb length of 180cm BMIlt50Banded Mini-Gastric Bypass(BMGB)(BOAGB)bull 9-18cm long pouch ~25cm widebull Ring 7-75 cmbull BP Limb length of 180cm BMI50
THE MOHAK PROTOCOLStandardized Bariatric and Robotic Surgery Operations
CHOICE OF PROCEDURE
Sleeve Gastrectomy (LSG) or Banded Sleeve Gastrectomy (BSG)bull Non-diabeticsbull No hiatal hernia or GERDbull HO Smokingbull HO alcohol usebull HO PUDbull Abnormal LFTs NASH and early Cirrhosisbull Pts from areas with high incidence of gastric cancer of H pylori infectionbull High risks patients and super obese patients as part of a two-staged operation
Gastric Bypass (LGBP) or Banded Gastric Bypass (BGBP) or Hybrid BGBPMGBbull Have T2DM with HgbA1c lt 8 and duration lt 5 yearsbull Have Hiatal hernia or GERDbull Are Vegetarianbull No nicotine addiction (smoking)bull Have HO Alcohol intake bull Have NASH at surgery-No cirrhosisbull Not likely to come back for follow up andbull Revision operation of Failed Sleeve gastrectomy GBP or MGB
MOHAK ALGORITHM
CHOICE OF PROCEDURE
One Anastomosis Gastric Bypass-Mini-Gastric Bypass (OAGBP-MGB) bull Have T2DM with HgbA1c 8 and durationgt5 yearsbull Have No GERDbull Are Non-vegetarianbull Have poor dentitionbull Most likely to return for follow up at the clinicbull No HO alcohol intakebull No Nicotine addiction (smoking)bull Normal LFTsbull No NASH at surgery or cirrhosisbull Commitment by our program to have 100 follow up of theses patient
Revision Operationbull Sleeve to Banded RY with 100 cm Al limb and 180 cm BP Limbbull MGB to diverted MGB for Reflux Existing BPL and 100cm ALbull MGB to GBP for PCM or reversal to normal anatomy for PCMmdashinterim gastrostomy feedingbull GBP to BGBP with 180cm BP limb for Weight regain or inadequate weight loss BMIlt40bull GBP to BGBP with 300cm common limb for Weight regain or inadequate weight loss BMIgt40
MOHAK ALGORITHM
CHOICE OF PROCEDURE
bull Laparoscopic Gastric Bypass
bull Laparoscopic Sleeve Gastrectomy
bull Divided Mini-Gastric Bypass
bull Biliopancreatic Diversion with DS
bull Single Anastomosis Duodeno-ileostomy
bull Gastric Plication
bull Banded Gastric Plication
bull Endoscopic Gastroplasty
bull Laparoscopic Adjustable Gastric bands
bull Balloon Implantation
bull Ileal interposition
These other operations will be used selectively based on patients needs and the surgeons determination
CHOICE OF PROCEDURE
The MOHAK Guide for Choice of Bariatric Metabolic Surgery Operations
Single Incision Laparoscopic Robotic and Endoscopic approaches are
available at patientsrsquo requests and the discretion of the surgeon
CHOICE OF PROCEDURE
The MOHAK Guide for Choice of Bariatric Metabolic Surgery Operations
Mohak Bariatrics and Robotics Surgery Center Motto
ldquoThe best operation for the patient by a competent surgeon in a well equipped hospital to maximize outcomes with the least amount of risks exposurerdquo
WE ARE ABLE TO CHOOSE THE BEST BARIATRIC METABOLIC PROCEDURE FOR YOUR PATIENT
Good long-term results are our marketing toolSuccessful patients make a lot of referralsbull
CHOICE OF PROCEDURE
The MOHAK Guide for Choice of Bariatric Metabolic Surgery Operations
We offer various treatment modalities for obesity The operation is
determined by the profile of the patient and guided by findings from
analysis of the data from our prospectively maintained database
MOHAK TEAM INDORE INDIA
THANK YOU
CHOOSING THE BEST BARIATRIC METABOLIC PROCEDURE FOR THE PATIENT
CHOICE OF PROCEDURE
Case 1128 y0 F BMI 42 PCO DUB OSA and HO Migraine headaches
AlgorithmSleeve GastrectomymdashPreferably a Ring banded Sleeve gastrectomy
----No T2DM---No GERDNot Gastric bypass mdash anemia smelly flatus
Not OAGBMGB----Anemia Foul smelling flatus and body odor----Protein deficiency
CHOOSING THE BEST BARIATRIC METABOLIC PROCEDURE FOR THE PATIENT
CHOICE OF PROCEDURE
Case 11137 yo Male BMI 68 OSA OA and a non vegetarian who works at your hospitalReferred by the pulmonologist at your medical Centre
Algorithm
OAGBMGBmdashHigh BMI Non Veg-better food tolerance patient very likely to be followedand to afford the supplements because of proximity to your center
Not sleeve---poor weight loss with sleeve in super obeseNot Banded sleeve---Good weight loss but poor food tolerance since patient is a non vegetarianNot Gastric bypass---Weight loss in super obese have high non response after gastric bypass
and the gastric bypass is technically a more difficult operation than the OAGBNot Banded gastric bypass ndashGood weight loss but a BGBP is a more difficult operation and
the patient will have some food intolerance because of the ring
SURGICAL TREATMENT OPTIONS
At Mohak we perform these standard three operations and their banded modifications
Sleeve Gastrectomy Gastric Bypass OAGBMGB
CHOICE OF PROCEDURE
Evidence based operations performed at MBRSC From 2010 t0 2017---Standardized OperationsLaparoscopic Sleeve Gastrectomybull 90-120 cc Sleevebull 2-5cm from pylorusbull Where a sleeve is indicated but a band is contraindicated or not affordableBanded Sleeve Gastrectomy (BSG) 84 EWL after 60 monthsbull 90-120 cc Sleevebull 2-5cm from pylorusbull Ring 65-75 cmbull At 3-6 cm below GE junctionBanded Gastric bypass (BGBP) 75 EWL 48 monthsbull Create 6mdash7cm long pouchbull 65-75 cm ring at 3-5 cm below GE junction and gt2cm above anastomosisbull Large Gastroenterostomy gt 2cm bull 100cm Roux Limb and 80 cm BP limb for BMIlt50bull 100cm Roux Limb and 150 cm BP limb for BMIgt50Mini-Gastric Bypass (MGB) (OAGB) 79 EWL 60 monthsbull 9-18cm long pouch ~25cm widebull BP Limb length of 180cm BMIlt50Banded Mini-Gastric Bypass(BMGB)(BOAGB)bull 9-18cm long pouch ~25cm widebull Ring 7-75 cmbull BP Limb length of 180cm BMI50
THE MOHAK PROTOCOLStandardized Bariatric and Robotic Surgery Operations
CHOICE OF PROCEDURE
Sleeve Gastrectomy (LSG) or Banded Sleeve Gastrectomy (BSG)bull Non-diabeticsbull No hiatal hernia or GERDbull HO Smokingbull HO alcohol usebull HO PUDbull Abnormal LFTs NASH and early Cirrhosisbull Pts from areas with high incidence of gastric cancer of H pylori infectionbull High risks patients and super obese patients as part of a two-staged operation
Gastric Bypass (LGBP) or Banded Gastric Bypass (BGBP) or Hybrid BGBPMGBbull Have T2DM with HgbA1c lt 8 and duration lt 5 yearsbull Have Hiatal hernia or GERDbull Are Vegetarianbull No nicotine addiction (smoking)bull Have HO Alcohol intake bull Have NASH at surgery-No cirrhosisbull Not likely to come back for follow up andbull Revision operation of Failed Sleeve gastrectomy GBP or MGB
MOHAK ALGORITHM
CHOICE OF PROCEDURE
One Anastomosis Gastric Bypass-Mini-Gastric Bypass (OAGBP-MGB) bull Have T2DM with HgbA1c 8 and durationgt5 yearsbull Have No GERDbull Are Non-vegetarianbull Have poor dentitionbull Most likely to return for follow up at the clinicbull No HO alcohol intakebull No Nicotine addiction (smoking)bull Normal LFTsbull No NASH at surgery or cirrhosisbull Commitment by our program to have 100 follow up of theses patient
Revision Operationbull Sleeve to Banded RY with 100 cm Al limb and 180 cm BP Limbbull MGB to diverted MGB for Reflux Existing BPL and 100cm ALbull MGB to GBP for PCM or reversal to normal anatomy for PCMmdashinterim gastrostomy feedingbull GBP to BGBP with 180cm BP limb for Weight regain or inadequate weight loss BMIlt40bull GBP to BGBP with 300cm common limb for Weight regain or inadequate weight loss BMIgt40
MOHAK ALGORITHM
CHOICE OF PROCEDURE
bull Laparoscopic Gastric Bypass
bull Laparoscopic Sleeve Gastrectomy
bull Divided Mini-Gastric Bypass
bull Biliopancreatic Diversion with DS
bull Single Anastomosis Duodeno-ileostomy
bull Gastric Plication
bull Banded Gastric Plication
bull Endoscopic Gastroplasty
bull Laparoscopic Adjustable Gastric bands
bull Balloon Implantation
bull Ileal interposition
These other operations will be used selectively based on patients needs and the surgeons determination
CHOICE OF PROCEDURE
The MOHAK Guide for Choice of Bariatric Metabolic Surgery Operations
Single Incision Laparoscopic Robotic and Endoscopic approaches are
available at patientsrsquo requests and the discretion of the surgeon
CHOICE OF PROCEDURE
The MOHAK Guide for Choice of Bariatric Metabolic Surgery Operations
Mohak Bariatrics and Robotics Surgery Center Motto
ldquoThe best operation for the patient by a competent surgeon in a well equipped hospital to maximize outcomes with the least amount of risks exposurerdquo
WE ARE ABLE TO CHOOSE THE BEST BARIATRIC METABOLIC PROCEDURE FOR YOUR PATIENT
Good long-term results are our marketing toolSuccessful patients make a lot of referralsbull
CHOICE OF PROCEDURE
The MOHAK Guide for Choice of Bariatric Metabolic Surgery Operations
We offer various treatment modalities for obesity The operation is
determined by the profile of the patient and guided by findings from
analysis of the data from our prospectively maintained database
MOHAK TEAM INDORE INDIA
THANK YOU
CHOOSING THE BEST BARIATRIC METABOLIC PROCEDURE FOR THE PATIENT
CHOICE OF PROCEDURE
Case 11137 yo Male BMI 68 OSA OA and a non vegetarian who works at your hospitalReferred by the pulmonologist at your medical Centre
Algorithm
OAGBMGBmdashHigh BMI Non Veg-better food tolerance patient very likely to be followedand to afford the supplements because of proximity to your center
Not sleeve---poor weight loss with sleeve in super obeseNot Banded sleeve---Good weight loss but poor food tolerance since patient is a non vegetarianNot Gastric bypass---Weight loss in super obese have high non response after gastric bypass
and the gastric bypass is technically a more difficult operation than the OAGBNot Banded gastric bypass ndashGood weight loss but a BGBP is a more difficult operation and
the patient will have some food intolerance because of the ring
SURGICAL TREATMENT OPTIONS
At Mohak we perform these standard three operations and their banded modifications
Sleeve Gastrectomy Gastric Bypass OAGBMGB
CHOICE OF PROCEDURE
Evidence based operations performed at MBRSC From 2010 t0 2017---Standardized OperationsLaparoscopic Sleeve Gastrectomybull 90-120 cc Sleevebull 2-5cm from pylorusbull Where a sleeve is indicated but a band is contraindicated or not affordableBanded Sleeve Gastrectomy (BSG) 84 EWL after 60 monthsbull 90-120 cc Sleevebull 2-5cm from pylorusbull Ring 65-75 cmbull At 3-6 cm below GE junctionBanded Gastric bypass (BGBP) 75 EWL 48 monthsbull Create 6mdash7cm long pouchbull 65-75 cm ring at 3-5 cm below GE junction and gt2cm above anastomosisbull Large Gastroenterostomy gt 2cm bull 100cm Roux Limb and 80 cm BP limb for BMIlt50bull 100cm Roux Limb and 150 cm BP limb for BMIgt50Mini-Gastric Bypass (MGB) (OAGB) 79 EWL 60 monthsbull 9-18cm long pouch ~25cm widebull BP Limb length of 180cm BMIlt50Banded Mini-Gastric Bypass(BMGB)(BOAGB)bull 9-18cm long pouch ~25cm widebull Ring 7-75 cmbull BP Limb length of 180cm BMI50
THE MOHAK PROTOCOLStandardized Bariatric and Robotic Surgery Operations
CHOICE OF PROCEDURE
Sleeve Gastrectomy (LSG) or Banded Sleeve Gastrectomy (BSG)bull Non-diabeticsbull No hiatal hernia or GERDbull HO Smokingbull HO alcohol usebull HO PUDbull Abnormal LFTs NASH and early Cirrhosisbull Pts from areas with high incidence of gastric cancer of H pylori infectionbull High risks patients and super obese patients as part of a two-staged operation
Gastric Bypass (LGBP) or Banded Gastric Bypass (BGBP) or Hybrid BGBPMGBbull Have T2DM with HgbA1c lt 8 and duration lt 5 yearsbull Have Hiatal hernia or GERDbull Are Vegetarianbull No nicotine addiction (smoking)bull Have HO Alcohol intake bull Have NASH at surgery-No cirrhosisbull Not likely to come back for follow up andbull Revision operation of Failed Sleeve gastrectomy GBP or MGB
MOHAK ALGORITHM
CHOICE OF PROCEDURE
One Anastomosis Gastric Bypass-Mini-Gastric Bypass (OAGBP-MGB) bull Have T2DM with HgbA1c 8 and durationgt5 yearsbull Have No GERDbull Are Non-vegetarianbull Have poor dentitionbull Most likely to return for follow up at the clinicbull No HO alcohol intakebull No Nicotine addiction (smoking)bull Normal LFTsbull No NASH at surgery or cirrhosisbull Commitment by our program to have 100 follow up of theses patient
Revision Operationbull Sleeve to Banded RY with 100 cm Al limb and 180 cm BP Limbbull MGB to diverted MGB for Reflux Existing BPL and 100cm ALbull MGB to GBP for PCM or reversal to normal anatomy for PCMmdashinterim gastrostomy feedingbull GBP to BGBP with 180cm BP limb for Weight regain or inadequate weight loss BMIlt40bull GBP to BGBP with 300cm common limb for Weight regain or inadequate weight loss BMIgt40
MOHAK ALGORITHM
CHOICE OF PROCEDURE
bull Laparoscopic Gastric Bypass
bull Laparoscopic Sleeve Gastrectomy
bull Divided Mini-Gastric Bypass
bull Biliopancreatic Diversion with DS
bull Single Anastomosis Duodeno-ileostomy
bull Gastric Plication
bull Banded Gastric Plication
bull Endoscopic Gastroplasty
bull Laparoscopic Adjustable Gastric bands
bull Balloon Implantation
bull Ileal interposition
These other operations will be used selectively based on patients needs and the surgeons determination
CHOICE OF PROCEDURE
The MOHAK Guide for Choice of Bariatric Metabolic Surgery Operations
Single Incision Laparoscopic Robotic and Endoscopic approaches are
available at patientsrsquo requests and the discretion of the surgeon
CHOICE OF PROCEDURE
The MOHAK Guide for Choice of Bariatric Metabolic Surgery Operations
Mohak Bariatrics and Robotics Surgery Center Motto
ldquoThe best operation for the patient by a competent surgeon in a well equipped hospital to maximize outcomes with the least amount of risks exposurerdquo
WE ARE ABLE TO CHOOSE THE BEST BARIATRIC METABOLIC PROCEDURE FOR YOUR PATIENT
Good long-term results are our marketing toolSuccessful patients make a lot of referralsbull
CHOICE OF PROCEDURE
The MOHAK Guide for Choice of Bariatric Metabolic Surgery Operations
We offer various treatment modalities for obesity The operation is
determined by the profile of the patient and guided by findings from
analysis of the data from our prospectively maintained database
MOHAK TEAM INDORE INDIA
THANK YOU
SURGICAL TREATMENT OPTIONS
At Mohak we perform these standard three operations and their banded modifications
Sleeve Gastrectomy Gastric Bypass OAGBMGB
CHOICE OF PROCEDURE
Evidence based operations performed at MBRSC From 2010 t0 2017---Standardized OperationsLaparoscopic Sleeve Gastrectomybull 90-120 cc Sleevebull 2-5cm from pylorusbull Where a sleeve is indicated but a band is contraindicated or not affordableBanded Sleeve Gastrectomy (BSG) 84 EWL after 60 monthsbull 90-120 cc Sleevebull 2-5cm from pylorusbull Ring 65-75 cmbull At 3-6 cm below GE junctionBanded Gastric bypass (BGBP) 75 EWL 48 monthsbull Create 6mdash7cm long pouchbull 65-75 cm ring at 3-5 cm below GE junction and gt2cm above anastomosisbull Large Gastroenterostomy gt 2cm bull 100cm Roux Limb and 80 cm BP limb for BMIlt50bull 100cm Roux Limb and 150 cm BP limb for BMIgt50Mini-Gastric Bypass (MGB) (OAGB) 79 EWL 60 monthsbull 9-18cm long pouch ~25cm widebull BP Limb length of 180cm BMIlt50Banded Mini-Gastric Bypass(BMGB)(BOAGB)bull 9-18cm long pouch ~25cm widebull Ring 7-75 cmbull BP Limb length of 180cm BMI50
THE MOHAK PROTOCOLStandardized Bariatric and Robotic Surgery Operations
CHOICE OF PROCEDURE
Sleeve Gastrectomy (LSG) or Banded Sleeve Gastrectomy (BSG)bull Non-diabeticsbull No hiatal hernia or GERDbull HO Smokingbull HO alcohol usebull HO PUDbull Abnormal LFTs NASH and early Cirrhosisbull Pts from areas with high incidence of gastric cancer of H pylori infectionbull High risks patients and super obese patients as part of a two-staged operation
Gastric Bypass (LGBP) or Banded Gastric Bypass (BGBP) or Hybrid BGBPMGBbull Have T2DM with HgbA1c lt 8 and duration lt 5 yearsbull Have Hiatal hernia or GERDbull Are Vegetarianbull No nicotine addiction (smoking)bull Have HO Alcohol intake bull Have NASH at surgery-No cirrhosisbull Not likely to come back for follow up andbull Revision operation of Failed Sleeve gastrectomy GBP or MGB
MOHAK ALGORITHM
CHOICE OF PROCEDURE
One Anastomosis Gastric Bypass-Mini-Gastric Bypass (OAGBP-MGB) bull Have T2DM with HgbA1c 8 and durationgt5 yearsbull Have No GERDbull Are Non-vegetarianbull Have poor dentitionbull Most likely to return for follow up at the clinicbull No HO alcohol intakebull No Nicotine addiction (smoking)bull Normal LFTsbull No NASH at surgery or cirrhosisbull Commitment by our program to have 100 follow up of theses patient
Revision Operationbull Sleeve to Banded RY with 100 cm Al limb and 180 cm BP Limbbull MGB to diverted MGB for Reflux Existing BPL and 100cm ALbull MGB to GBP for PCM or reversal to normal anatomy for PCMmdashinterim gastrostomy feedingbull GBP to BGBP with 180cm BP limb for Weight regain or inadequate weight loss BMIlt40bull GBP to BGBP with 300cm common limb for Weight regain or inadequate weight loss BMIgt40
MOHAK ALGORITHM
CHOICE OF PROCEDURE
bull Laparoscopic Gastric Bypass
bull Laparoscopic Sleeve Gastrectomy
bull Divided Mini-Gastric Bypass
bull Biliopancreatic Diversion with DS
bull Single Anastomosis Duodeno-ileostomy
bull Gastric Plication
bull Banded Gastric Plication
bull Endoscopic Gastroplasty
bull Laparoscopic Adjustable Gastric bands
bull Balloon Implantation
bull Ileal interposition
These other operations will be used selectively based on patients needs and the surgeons determination
CHOICE OF PROCEDURE
The MOHAK Guide for Choice of Bariatric Metabolic Surgery Operations
Single Incision Laparoscopic Robotic and Endoscopic approaches are
available at patientsrsquo requests and the discretion of the surgeon
CHOICE OF PROCEDURE
The MOHAK Guide for Choice of Bariatric Metabolic Surgery Operations
Mohak Bariatrics and Robotics Surgery Center Motto
ldquoThe best operation for the patient by a competent surgeon in a well equipped hospital to maximize outcomes with the least amount of risks exposurerdquo
WE ARE ABLE TO CHOOSE THE BEST BARIATRIC METABOLIC PROCEDURE FOR YOUR PATIENT
Good long-term results are our marketing toolSuccessful patients make a lot of referralsbull
CHOICE OF PROCEDURE
The MOHAK Guide for Choice of Bariatric Metabolic Surgery Operations
We offer various treatment modalities for obesity The operation is
determined by the profile of the patient and guided by findings from
analysis of the data from our prospectively maintained database
MOHAK TEAM INDORE INDIA
THANK YOU
Evidence based operations performed at MBRSC From 2010 t0 2017---Standardized OperationsLaparoscopic Sleeve Gastrectomybull 90-120 cc Sleevebull 2-5cm from pylorusbull Where a sleeve is indicated but a band is contraindicated or not affordableBanded Sleeve Gastrectomy (BSG) 84 EWL after 60 monthsbull 90-120 cc Sleevebull 2-5cm from pylorusbull Ring 65-75 cmbull At 3-6 cm below GE junctionBanded Gastric bypass (BGBP) 75 EWL 48 monthsbull Create 6mdash7cm long pouchbull 65-75 cm ring at 3-5 cm below GE junction and gt2cm above anastomosisbull Large Gastroenterostomy gt 2cm bull 100cm Roux Limb and 80 cm BP limb for BMIlt50bull 100cm Roux Limb and 150 cm BP limb for BMIgt50Mini-Gastric Bypass (MGB) (OAGB) 79 EWL 60 monthsbull 9-18cm long pouch ~25cm widebull BP Limb length of 180cm BMIlt50Banded Mini-Gastric Bypass(BMGB)(BOAGB)bull 9-18cm long pouch ~25cm widebull Ring 7-75 cmbull BP Limb length of 180cm BMI50
THE MOHAK PROTOCOLStandardized Bariatric and Robotic Surgery Operations
CHOICE OF PROCEDURE
Sleeve Gastrectomy (LSG) or Banded Sleeve Gastrectomy (BSG)bull Non-diabeticsbull No hiatal hernia or GERDbull HO Smokingbull HO alcohol usebull HO PUDbull Abnormal LFTs NASH and early Cirrhosisbull Pts from areas with high incidence of gastric cancer of H pylori infectionbull High risks patients and super obese patients as part of a two-staged operation
Gastric Bypass (LGBP) or Banded Gastric Bypass (BGBP) or Hybrid BGBPMGBbull Have T2DM with HgbA1c lt 8 and duration lt 5 yearsbull Have Hiatal hernia or GERDbull Are Vegetarianbull No nicotine addiction (smoking)bull Have HO Alcohol intake bull Have NASH at surgery-No cirrhosisbull Not likely to come back for follow up andbull Revision operation of Failed Sleeve gastrectomy GBP or MGB
MOHAK ALGORITHM
CHOICE OF PROCEDURE
One Anastomosis Gastric Bypass-Mini-Gastric Bypass (OAGBP-MGB) bull Have T2DM with HgbA1c 8 and durationgt5 yearsbull Have No GERDbull Are Non-vegetarianbull Have poor dentitionbull Most likely to return for follow up at the clinicbull No HO alcohol intakebull No Nicotine addiction (smoking)bull Normal LFTsbull No NASH at surgery or cirrhosisbull Commitment by our program to have 100 follow up of theses patient
Revision Operationbull Sleeve to Banded RY with 100 cm Al limb and 180 cm BP Limbbull MGB to diverted MGB for Reflux Existing BPL and 100cm ALbull MGB to GBP for PCM or reversal to normal anatomy for PCMmdashinterim gastrostomy feedingbull GBP to BGBP with 180cm BP limb for Weight regain or inadequate weight loss BMIlt40bull GBP to BGBP with 300cm common limb for Weight regain or inadequate weight loss BMIgt40
MOHAK ALGORITHM
CHOICE OF PROCEDURE
bull Laparoscopic Gastric Bypass
bull Laparoscopic Sleeve Gastrectomy
bull Divided Mini-Gastric Bypass
bull Biliopancreatic Diversion with DS
bull Single Anastomosis Duodeno-ileostomy
bull Gastric Plication
bull Banded Gastric Plication
bull Endoscopic Gastroplasty
bull Laparoscopic Adjustable Gastric bands
bull Balloon Implantation
bull Ileal interposition
These other operations will be used selectively based on patients needs and the surgeons determination
CHOICE OF PROCEDURE
The MOHAK Guide for Choice of Bariatric Metabolic Surgery Operations
Single Incision Laparoscopic Robotic and Endoscopic approaches are
available at patientsrsquo requests and the discretion of the surgeon
CHOICE OF PROCEDURE
The MOHAK Guide for Choice of Bariatric Metabolic Surgery Operations
Mohak Bariatrics and Robotics Surgery Center Motto
ldquoThe best operation for the patient by a competent surgeon in a well equipped hospital to maximize outcomes with the least amount of risks exposurerdquo
WE ARE ABLE TO CHOOSE THE BEST BARIATRIC METABOLIC PROCEDURE FOR YOUR PATIENT
Good long-term results are our marketing toolSuccessful patients make a lot of referralsbull
CHOICE OF PROCEDURE
The MOHAK Guide for Choice of Bariatric Metabolic Surgery Operations
We offer various treatment modalities for obesity The operation is
determined by the profile of the patient and guided by findings from
analysis of the data from our prospectively maintained database
MOHAK TEAM INDORE INDIA
THANK YOU
Sleeve Gastrectomy (LSG) or Banded Sleeve Gastrectomy (BSG)bull Non-diabeticsbull No hiatal hernia or GERDbull HO Smokingbull HO alcohol usebull HO PUDbull Abnormal LFTs NASH and early Cirrhosisbull Pts from areas with high incidence of gastric cancer of H pylori infectionbull High risks patients and super obese patients as part of a two-staged operation
Gastric Bypass (LGBP) or Banded Gastric Bypass (BGBP) or Hybrid BGBPMGBbull Have T2DM with HgbA1c lt 8 and duration lt 5 yearsbull Have Hiatal hernia or GERDbull Are Vegetarianbull No nicotine addiction (smoking)bull Have HO Alcohol intake bull Have NASH at surgery-No cirrhosisbull Not likely to come back for follow up andbull Revision operation of Failed Sleeve gastrectomy GBP or MGB
MOHAK ALGORITHM
CHOICE OF PROCEDURE
One Anastomosis Gastric Bypass-Mini-Gastric Bypass (OAGBP-MGB) bull Have T2DM with HgbA1c 8 and durationgt5 yearsbull Have No GERDbull Are Non-vegetarianbull Have poor dentitionbull Most likely to return for follow up at the clinicbull No HO alcohol intakebull No Nicotine addiction (smoking)bull Normal LFTsbull No NASH at surgery or cirrhosisbull Commitment by our program to have 100 follow up of theses patient
Revision Operationbull Sleeve to Banded RY with 100 cm Al limb and 180 cm BP Limbbull MGB to diverted MGB for Reflux Existing BPL and 100cm ALbull MGB to GBP for PCM or reversal to normal anatomy for PCMmdashinterim gastrostomy feedingbull GBP to BGBP with 180cm BP limb for Weight regain or inadequate weight loss BMIlt40bull GBP to BGBP with 300cm common limb for Weight regain or inadequate weight loss BMIgt40
MOHAK ALGORITHM
CHOICE OF PROCEDURE
bull Laparoscopic Gastric Bypass
bull Laparoscopic Sleeve Gastrectomy
bull Divided Mini-Gastric Bypass
bull Biliopancreatic Diversion with DS
bull Single Anastomosis Duodeno-ileostomy
bull Gastric Plication
bull Banded Gastric Plication
bull Endoscopic Gastroplasty
bull Laparoscopic Adjustable Gastric bands
bull Balloon Implantation
bull Ileal interposition
These other operations will be used selectively based on patients needs and the surgeons determination
CHOICE OF PROCEDURE
The MOHAK Guide for Choice of Bariatric Metabolic Surgery Operations
Single Incision Laparoscopic Robotic and Endoscopic approaches are
available at patientsrsquo requests and the discretion of the surgeon
CHOICE OF PROCEDURE
The MOHAK Guide for Choice of Bariatric Metabolic Surgery Operations
Mohak Bariatrics and Robotics Surgery Center Motto
ldquoThe best operation for the patient by a competent surgeon in a well equipped hospital to maximize outcomes with the least amount of risks exposurerdquo
WE ARE ABLE TO CHOOSE THE BEST BARIATRIC METABOLIC PROCEDURE FOR YOUR PATIENT
Good long-term results are our marketing toolSuccessful patients make a lot of referralsbull
CHOICE OF PROCEDURE
The MOHAK Guide for Choice of Bariatric Metabolic Surgery Operations
We offer various treatment modalities for obesity The operation is
determined by the profile of the patient and guided by findings from
analysis of the data from our prospectively maintained database
MOHAK TEAM INDORE INDIA
THANK YOU
One Anastomosis Gastric Bypass-Mini-Gastric Bypass (OAGBP-MGB) bull Have T2DM with HgbA1c 8 and durationgt5 yearsbull Have No GERDbull Are Non-vegetarianbull Have poor dentitionbull Most likely to return for follow up at the clinicbull No HO alcohol intakebull No Nicotine addiction (smoking)bull Normal LFTsbull No NASH at surgery or cirrhosisbull Commitment by our program to have 100 follow up of theses patient
Revision Operationbull Sleeve to Banded RY with 100 cm Al limb and 180 cm BP Limbbull MGB to diverted MGB for Reflux Existing BPL and 100cm ALbull MGB to GBP for PCM or reversal to normal anatomy for PCMmdashinterim gastrostomy feedingbull GBP to BGBP with 180cm BP limb for Weight regain or inadequate weight loss BMIlt40bull GBP to BGBP with 300cm common limb for Weight regain or inadequate weight loss BMIgt40
MOHAK ALGORITHM
CHOICE OF PROCEDURE
bull Laparoscopic Gastric Bypass
bull Laparoscopic Sleeve Gastrectomy
bull Divided Mini-Gastric Bypass
bull Biliopancreatic Diversion with DS
bull Single Anastomosis Duodeno-ileostomy
bull Gastric Plication
bull Banded Gastric Plication
bull Endoscopic Gastroplasty
bull Laparoscopic Adjustable Gastric bands
bull Balloon Implantation
bull Ileal interposition
These other operations will be used selectively based on patients needs and the surgeons determination
CHOICE OF PROCEDURE
The MOHAK Guide for Choice of Bariatric Metabolic Surgery Operations
Single Incision Laparoscopic Robotic and Endoscopic approaches are
available at patientsrsquo requests and the discretion of the surgeon
CHOICE OF PROCEDURE
The MOHAK Guide for Choice of Bariatric Metabolic Surgery Operations
Mohak Bariatrics and Robotics Surgery Center Motto
ldquoThe best operation for the patient by a competent surgeon in a well equipped hospital to maximize outcomes with the least amount of risks exposurerdquo
WE ARE ABLE TO CHOOSE THE BEST BARIATRIC METABOLIC PROCEDURE FOR YOUR PATIENT
Good long-term results are our marketing toolSuccessful patients make a lot of referralsbull
CHOICE OF PROCEDURE
The MOHAK Guide for Choice of Bariatric Metabolic Surgery Operations
We offer various treatment modalities for obesity The operation is
determined by the profile of the patient and guided by findings from
analysis of the data from our prospectively maintained database
MOHAK TEAM INDORE INDIA
THANK YOU
bull Laparoscopic Gastric Bypass
bull Laparoscopic Sleeve Gastrectomy
bull Divided Mini-Gastric Bypass
bull Biliopancreatic Diversion with DS
bull Single Anastomosis Duodeno-ileostomy
bull Gastric Plication
bull Banded Gastric Plication
bull Endoscopic Gastroplasty
bull Laparoscopic Adjustable Gastric bands
bull Balloon Implantation
bull Ileal interposition
These other operations will be used selectively based on patients needs and the surgeons determination
CHOICE OF PROCEDURE
The MOHAK Guide for Choice of Bariatric Metabolic Surgery Operations
Single Incision Laparoscopic Robotic and Endoscopic approaches are
available at patientsrsquo requests and the discretion of the surgeon
CHOICE OF PROCEDURE
The MOHAK Guide for Choice of Bariatric Metabolic Surgery Operations
Mohak Bariatrics and Robotics Surgery Center Motto
ldquoThe best operation for the patient by a competent surgeon in a well equipped hospital to maximize outcomes with the least amount of risks exposurerdquo
WE ARE ABLE TO CHOOSE THE BEST BARIATRIC METABOLIC PROCEDURE FOR YOUR PATIENT
Good long-term results are our marketing toolSuccessful patients make a lot of referralsbull
CHOICE OF PROCEDURE
The MOHAK Guide for Choice of Bariatric Metabolic Surgery Operations
We offer various treatment modalities for obesity The operation is
determined by the profile of the patient and guided by findings from
analysis of the data from our prospectively maintained database
MOHAK TEAM INDORE INDIA
THANK YOU
Single Incision Laparoscopic Robotic and Endoscopic approaches are
available at patientsrsquo requests and the discretion of the surgeon
CHOICE OF PROCEDURE
The MOHAK Guide for Choice of Bariatric Metabolic Surgery Operations
Mohak Bariatrics and Robotics Surgery Center Motto
ldquoThe best operation for the patient by a competent surgeon in a well equipped hospital to maximize outcomes with the least amount of risks exposurerdquo
WE ARE ABLE TO CHOOSE THE BEST BARIATRIC METABOLIC PROCEDURE FOR YOUR PATIENT
Good long-term results are our marketing toolSuccessful patients make a lot of referralsbull
CHOICE OF PROCEDURE
The MOHAK Guide for Choice of Bariatric Metabolic Surgery Operations
We offer various treatment modalities for obesity The operation is
determined by the profile of the patient and guided by findings from
analysis of the data from our prospectively maintained database
MOHAK TEAM INDORE INDIA
THANK YOU
Mohak Bariatrics and Robotics Surgery Center Motto
ldquoThe best operation for the patient by a competent surgeon in a well equipped hospital to maximize outcomes with the least amount of risks exposurerdquo
WE ARE ABLE TO CHOOSE THE BEST BARIATRIC METABOLIC PROCEDURE FOR YOUR PATIENT
Good long-term results are our marketing toolSuccessful patients make a lot of referralsbull
CHOICE OF PROCEDURE
The MOHAK Guide for Choice of Bariatric Metabolic Surgery Operations
We offer various treatment modalities for obesity The operation is
determined by the profile of the patient and guided by findings from
analysis of the data from our prospectively maintained database
MOHAK TEAM INDORE INDIA
THANK YOU
We offer various treatment modalities for obesity The operation is
determined by the profile of the patient and guided by findings from
analysis of the data from our prospectively maintained database
MOHAK TEAM INDORE INDIA
THANK YOU