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Bariatric Surgery is rapidly gaining popularity. Knowing the right Indications and Contra Indications is paramount for Surgeons starting their career in Bariatric Surgery.
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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