Indications & c.i in bariatric surgery

SENIOR CONSULTANT & COORDINATOR

MINIMAL ACCESS, METABOLIC & BARIATRIC SURGERY

DR. SUMEET SHAH MS, DNB, MNAMS, FIAGESFellowship (Minimal Access Surgery)

MAX SUPER SPECIALTY HOSPITAL, SHALIMAR BAGH NEW DELHI (INDIA)

Bariatric SurgeryIndications & Contraindications

Bariatric SurgeryIndications & Contraindications

What is obesity?

?

Morbid obesity is a chronic, lifelong,

multifactorial, genetically related disease

of excessive fat storage with highly

significant medical, psychological,

social, physical and economic co-

morbiditiesIFSO Sept, 1996

Bariatric SurgeryIndications & Contraindications

Bariatric SurgeryIndications & Contraindications

Quantification of obesity

BMI = Body Mass Index

= Body weight (Kg)

Height (in m2)

BARIATRIC RECOMMENDATIONS WHO CRITERIA RECOMMENDATION

FOR ASIANS

BMI (kg per m2)

Normal < 25.0 < 23.0

Overweight > 25.0 > 23.0

Obese > 30.0 > 27.5

Severe Obesity > 35.0 > 32.5

Morbid Obesity > 40.0 > 37.5

Bariatric SurgeryIndications & Contraindications

~77 % Excess weight loss ~ 85 % resolution of OSA ~ 52 to 92 % resolution of HTN ~ 73 – 83% resolution of type 2 diabetes > 80 % resolution of Metabolic Syndrome

Sjostrom et al New Engl J Med 2004Sjostrom et al, N Engl J Med 2007

Bariatric Surgery: Multiple Health Benefits

Bariatric SurgeryIndications & Contraindications

Bariatric SurgeryIndications & Contraindications

Assess indications / contraindications Multi-disciplinary evaluation Optimize & manage comorbidities Educate,set realistic expectations

Optimal Patient Selection

Bariatric SurgeryIndications & Contraindications

NIH Consensus Conference Criteria(1991)

BMI > 40 or > 35 kg/m2 with co-morbidity

Failure of non-operative Rx

Absence of contraindications

Well informed, compliant, motivated patient

Bariatric SurgeryIndications & Contraindications

Surgery for Adolescents & Elderly

( Age < 18 / > 65 yrs )

Surgery for BMI < 35

Surgery for Metabolic indications only

Controversies

Bariatric SurgeryIndications & Contraindications

Adolescent bariatric surgery (<18 yrs) has proven

effective but should be performed only in a

specialty centre

Selection criteria similar

to adults

SAGES Guidelines for Clinical Application of Laparoscopic Bariatric Surgery, 2008; Level II, Grade B,C evidence.

? Surgery for Adolescents

Bariatric SurgeryIndications & Contraindications

Panel of experts on Adolescent Obesity BMI > 40 with comorbidities Skeletal / physiologic maturity Failure of > 6 mths of structured wt loss attempts Commitment, ability to follow post-op instructions Decision making capacity Commitment to avoid pregnancy x 1 year

Curr Opin Paediatr 2005.

Bariatric SurgeryIndications & Contraindications

Patients > 65 yrs at risk of death (early & late) after WLS

Should have life expectancy > 5 yrs

Should be evaluated & treated in

an established Center of ExcellenceJAMA 2005Annals of Surgery 2004SAGES Guidelines for Clinical Application of LaparoscopicBariatric Surgery, 2008; Level II, Grade B evidence.

? Surgery for Age > 65

Bariatric SurgeryIndications & Contraindications

“Individuals with BMI 30-35 kg/m2 may benefit from Lap. bariatric surgery given

the poor results of non-surgical Rx”

SAGES Guidelines for Clinical Application of Laparoscopic Bariatric Surgery, 2008; Level I, Grade B evidence.

? Surgery for BMI < 35

Surgery for Diabetes / Metabolic Syndrome

Risks vs Benefits?

Choice of procedure?

Economic Considerations?

When to intervene?

? BMI < 35

?

Bariatric SurgeryIndications & Contraindications

Contraindications

Bariatric SurgeryIndications & Contraindications

Bariatric SurgeryIndications & Contraindications

Severe co-morbidities / unacceptable risk

Uncontrolled coagulopathy

Incurable disease (cancer,AIDS, cirrhosis)

? Certain GI diseases (Crohns, dysmotilities)

V.Poor QOL not expected to improve with WLS

Medical

Bariatric SurgeryIndications & Contraindications

Uncontrolled severe OSA + Pulmonary HTN

(Pulm. Syst. Pressure > 50mm Hg)

Severe COPD (Gold Spirometric Criteria)

- FEV1 / FVC < 0.7

- FEV1 < 30% predicted, or

- FEV1 < 50% predicted + chr. resp. failure

CHF, unstable angina ? Complete prolonged immobility

Unacceptable risk of Anaesthesia

Bariatric SurgeryIndications & Contraindications

Multiple previous surgeries

Abdominal irradiation / Liver transplant

Very large incisional hernia

Previous int. resection for GBP / BPD-DS

Severe GERD / Barrets for LAGB

Need for surveillance endoscopy for GBP

Surgical (Relative)

Bariatric SurgeryIndications & Contraindications

Significant psychatric dis./ major depression Severe mental retardation Self destructive tendency Active bullimia, drug or alcohol abuse Inability to comprehend behavioral changes Inability to integrate basic lifestyle adjustments

Behavioral / Psychosocial

Bariatric SurgeryIndications & Contraindications

Extreme hepatomegaly / cirrhosis with large varices

Profuse visceral fat Poor exposure Extensive adhesions Cardiopulmonary instability

Indications for Retreat / Change of surgical plan

Bariatric SurgeryIndications & Contraindications

Indications for Retreat / Change of surgical plan

Bariatric SurgeryIndications & Contraindications

Early Gastric perforation Stomach slippage

Late Stomach slippage Malpositioned band Erosion Psychological intolerance AIDS Gastric necrosis

Revision Surgery: After Lap. Gastric Banding

Bariatric SurgeryIndications & Contraindications

Mechanical problems

Marginal ulcer

Refractory GJ stricture

Entero-enterostomy stenosis

Revision Surgery: After Lap. Gastric Bypass

Bariatric SurgeryIndications & Contraindications

Insufficient Weight loss Normal anatomy Abnormal anatomy

- Disrupted staple line

- Gastro-gastric fistula in divided GBP

- Enlarged pouch

Metabolic / Functional Nut. deficiency / food intolerance Severe dumping / unexplained chronic pain

Revision Surgery: After Lap. Gastric Bypass

Bariatric SurgeryIndications & Contraindications

Bariatric SurgeryIndications & Contraindications

Bariatric SurgeryIndications & Contraindications