Bariatric Surgery

Mr Peter O’Leary

History

Greek Baros = weight Iatros = physician

Kremen & Linner 1954 Jejuno-ileal Bypass

Mason 1967 Gastric Bypass Failure to gain weight post partial

gastrectomy for peptic ulcer disease

Recognised as a general surgical sub-speciality by American College of Surgeons American Medical Association

Mrs. KG (48) Referred by Orthopaedics re Gastric bypass for:

Weight reduction prior to hip replacement (OA)Improvement of mobilitySeeking procedure for 4 year

Current status Weight 135kg

Height1.75m

BMI 47

HxPC

>9st until mid 20s

Gained weight since the birth of her children

Weight reduction measuresWeight watchersDieticiansAppetite suppressantsAll effective short term

MedHx Osteoarthritis B/L hip Hypertension Hypercholestrolaemia Sleep apnoea Reflux and heart burn

NIDDM

Family Hx Nil of note

Drug Hx NKDA Metformin Atenolol

SHx Non-smoker No alcholo Shop assistant

RoS Nil of note

On Examination

Looked well but obese

Vitals normal

MSS Fixed flexion R knee

Joint line tender medially

Crepitus +

CVS, RS, Neuro - NAD

Pre-op Advice

Advised about Procedure

Possible complication Post-op recovery

Endocrine assessment No pre-op consultation with Dietician No pre-op psychological evaluation

Indications BMI > 40 (> 35 with co-morbid conditions)

sleep apnea cardiomyopathy diabetes mellitus musculoskeletal body size severely impacting on function

No medical or anaesthetic contraindications

No previous major upper abdominal surgery

No active drug or alcohol addiction history

No major psychiatric history

Well informed, motivated, and acceptable operative risks

Pre-op Considerations Endocrinologist

Pituitary Thyroid Adrenal

Dietician Eating behaviour modification Post op diet adjustment, vitamin and

mineral supplementation

Psychological evaluation Psychiatric co-morbidities Change in relationship with food Behaviour modification techniques

Please help…!

QuickTime™ and aTIFF (Uncompressed) decompressor

are needed to see this picture.

Bariatric surgery

weight reduction surgery for morbidly obese1.BMI >40 (basically, >100 pounds above ideal

body weight).

2.BMI >35 with a medical problem related to morbid obesity.

Surgical options

Stapling off of small gastric pouch (restrictive) roux-en-Y limb to gastric pouch

QuickTime™ and aTIFF (Uncompressed) decompressor

are needed to see this picture.

Mechanism of gastric by pass

1. Creates a small gastric reservoir

2. Causes dumping symptoms when a patient eats too much food or high calorie foods, the food is dumped into the roux-en-Y limb

3. Bypass of small bowel by roux-en-Y limb

QuickTime™ and aTIFF (Uncompressed) decompressor

are needed to see this picture.

Dose gastric by pass work?

Weight loss 50% of excess weight QuickTime™ and a

TIFF (Uncompressed) decompressorare needed to see this picture.

Postop Complications Early (1 to 6 weeks)

Postoperative bleeding Anastomosis leak Bowel perforation Bowel obstruction Wound infections

Intermediate (7 to 12 weeks) Prolonged vomiting

Dietary indiscretions Bulimia Stricture at gastrojejunal anastomosis (4.6%)

Marginal ulcer Dumping syndrome (50% after roux en y)

Late (13 weeks to 12 months) Cholelithiasis Small bowel obstruction (adhesions) Secondary hyperparathyroidism

Leak after gastric

bypass on upper gastrointestinal series

Long term eating habits Initially, the stomach tolerates 30 cc at one time 3 months, patients are ingesting ~1000 kcal in three to six

meals per day Dietary advice important at this stage

Six months, should be on 3 meals a day Food aversions develop esp if prolonged vomiting associated

with eating Such patients often express "buyers remorse" and may request

extensive investigations for problems with the gastric pouch Eating habits change compared to preoperative eating habits

Fresh fruits and vegetables are tolerated without a problem Some patients have continuing food intolerances, especially to red

meat, and become vegetarian

Changes post surgery Weight loss

Rapid in the first six months Averages 4 to 7 Kg per month

Slows 2 to 3 Kg after 6 months Total weight loss peaks at 12 months Weight regain 18-24 months post op

Nutritional Deficiencies Inadequate intake of nutrients Alterations in the digestive anatomy

lack of intrinsic factor – B12 def Lack of acid in new pouch (R en Y) – Poor absorption of iron Ca and Vit D absorption decreased after surgery – Secondary Hyperthyroidism Thiamine def due to recurrent vomiting Little evidence available on the amount of supplementation required

Cosmetic After 12 months, patients seek info about plastic surgery to remove abdominal

pannus Insurance companies will not cover it - cosmetic Exception if abdominal pannus becomes infected or excoriated Case series suggested that delaying panniculectomy until after weight loss is safer

and more effective

Physical function Fatigue improves, increased energy Exercise habits improve

increase in activities of daily living and recreational activities Musculoskeletal and back pain improves or resolves in the majority of patients Osteoarthritis improves to a lesser degree

Dependent on the degree of underlying bone and cartilage damage Sleep apnea improves

Psychological Lethargy, depression, and other psychopathology Food used for emotional reasons, pre-op Grieve the loss of food Several studies have shown increases in self-esteem, self-

confidence, assertiveness, and expressiveness Improvements seen in social interaction, sexual activity, and

work performance

Pregnancy Greater fertility with weight loss Surgery not associated with adverse perinatal outcomes Pregnancy complications eg gestational diabetes, hypertension, and

macrosomia Period of rapid weight loss Gastric band may need to be adjusted nutritional deficiencies

"un poco con la cabeza de Maradona y otro poco con la mano de Dios"