Bariatric Surgery

Nicole Mancinelli

Objectives Be familiar with the most common types

of bariatric surgery procedures performed today.

Learn the criteria that need to be met to be considered a candidate for surgery.

Be familiar with the advantages/disadvantages of the most common procedures.

Burden of Obesity

Approx.72.5 million adults considered obese in 2007-2008

Biggest contributor of healthcare spending over last 20 yrs

Oklahoma was ranked 7th most obese state in 2011

CDC

History of Bariatric Surgery

1954: first introduced by Kremen 1976: safer approach developed by

Scopinaro 1988: crossbreed of Biliopancreatic

diversion developed by Hess 1994: laproscopy was introduced by

Wittgrove

Maggard et al. Scopinaro et al.

Qualification for Surgery

BMI ≥40 kg/m2

BMI ≥35 kg/m2 + co-morbidities of obesity

Failed conventional weight control

Padwell et al.

Current Surgical Procedures Adjustable gastric banding

Vertical banded gastroplasty

Roux-en-Y procedure

Laproscopic sleeve gastrectomy

Biliopancreatic Diversion with duodenal switch

Vertical Banded Gastroplasty

Created in 1982

Band/staples used to create a small stomach pouch

Limited weight loss results and high re-operation rates

Up to 56% as compared to other procedures

Complications: Stromal erosion, weight

regain, severe GER symptoms

Lap Sleeve Gastrectomy

Fairly new restrictive procedure

Originally created as a bridging procedure

Ranked between LAGB and Roux en Y

More data needed to determine relative benefits

Biliopancreatic Diversion with Duodenal Switch Originally created in 1988 for

treatment of bile gastritis

Decrease usage due to increased risk of micro/macro nutritional deficiencies

Increased risk for metabolic consequences

Protein malnutrition Fe deficiency anemia Hypocalcemia

Develop bone demineralization that could double fracture risk

Adjustable Gastric Banding

Approved in 2001

Ability to fine tune desired effects of silicone band and decrease adverse effects

Lowest morbidity and mortality among bariatric procedures

Disadvantages Foreign object Stomach prolapse Inferior weight loss when

compared to Roux en Y

Long term efficacy/Safety

Followed 82 pts Jan. 1994- Dec 1997 22% experienced minor complications

Incisional hernia, port tube disconnections, infection

39% (23)experienced major complications Dilation of pouch, erosion

Re-operations 49 (59.8%) due to lack weight loss

Mean BMI ↓ from 41.57 to 33.79 Nearly 50% required removal band, 1out of 3 had

band erosion

Scozarri et al.

Roux-en Y Procedure

First appeared in 1967

Most widely performed

Combo of restrictive/ malabsorption

Roux limb varies and each has its own advantages

Best results for long term weight loss, decrease GERD symptoms 95% of pts

RYGB vs LAG

Prospective randomized study

196 pts 111 LRYGB

Mean BMI 47.5 kg/m2 86 LAG

Mean BMI 45.5kg/m2

Weight loss Results

Early/ Late Complications

Long term consequences

Improves associated co-morbities related to obesity Diabetes Sleep Apnea HTN

>75% had HTN prior to surgery 69% reported HTN resolved in 1 year and

sustained over 7 years GERD

>50% obese have GERD, >95% had resolution after bariatric procedure

DM

Prevalence of DM in 1990Prevalence of DM in 1990

Prevalence of DM 1997-1998Prevalence of DM 1997-1998

Mokdad et al.

Efficacy of surgery in the management of obesity related type 2 Diabetes Mellitus

Gan et al

Nutritional Deficiencies

Fe Deficiency > 50% were below pre op levels despite

adequate oral supplements Only 3.5% required transfusion

B12

Most commonly after RYGB Below normal in 26% of 66 pts after RYGB

Calcium Deficiency243 pts followed after RYGB

Johnson et al.

Dumping Syndrome

Caused when ingested food bypasses the stomach too rapidly and enters the small intestine largely undigested Expansion of the duodenum occurs too

quickly due to the presence of hyperosmolar food from the stomach

>70% of individuals experienced at least one symptom of this syndrome after RYGB

Future of Bariatric Surgery

Single incision Uses silicone band

around upper portion of the stomach

Incision Free Transoral

gastroplasty Endolumenal Both create stapled,

restrictive pouch

Conclusion

Most common bariatric procedures are Roux en Y, and Adjustable Gastric Band

Certain procedures should be selected based on multiple factors

References Scozzari, MD, Toppino M, Famiglietti F, et al. 10 year follow up of

laparoscopic Vertical banded gastroplasty. Annals of Surgery. November 2010; 225 (5): 831-839.

CDC. State-specific prevalence of obesity among adults- United States, 2009. MMWR 2010:59;951-955.

Padwal R, Klarenbach S, Tonelli M, et al. Bariatric Surgery: A systematic Review of the Clinical and Economic Evidence. JGIM: Journal of General Internal Medicine. October 2011;26 (10):1183-1194.

Suter M, Donadini A, Romy S, Demartines N, Giusti V. Laproscopic Roux-en-Y Gastric Bypass: Significant Long term weight loss, Improvement of Obesity-related Comorbidities and Quality of Life. Annals of Surgery. 2011;254 (2): 267-273.

Gan S. Talbot M, Jorgensen J. Efficacy of Surgery in the management of obesity related type 2 diabetes mellitus. Surgery. October 2007; 77:958-962.

References

Johnson J, Maher J, DeMaria E, Downs R, Wolfe L, Kellum J. The Long term effects of Gastric Bypass on Vitamin D Metabolism. Annals of Surgery. Scientific Papers of the 117th Annual Meeting of the Southern Surgical Association. 2006: 243 (5): 701-705.

Mokad A, Ford E, Bowman B, Nelson D, Engelgau M, Vinicor F, Marks J. Diabetes trends in the US: 1990-1998. Diabetes Care. September 2000; 23:1278-1283.

Maggard MA, Shugarman LR, Suttorp M, et al. Meta-analysis: Surgical treatment of obesity. Annals of Internal Medicine. 2005; 142:547-559.

Scopinaro N, Adami GF, Marinarir GM, et al. Biliopancreatic Diversion. World Journal of Surgery. 1998; 22:936-946.

Special Thanks to G. Michael Steelman M.D.