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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.