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Bariatric Suregry, Gastrectomy, Roux-en-Y bipass for morbid obesity, Morbid Obesity, Gasrtric banding, Bilio-Pancreatic Bipass, Duodenal switch.
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BARIATRIC SURGERY
Dr. Onkar Singh, Dr. Shilpi Gupta,Dr. Praveen Baghel, Dr. Mohan Soni
-MGM Medical College & MY Hospital, Indore, India.
Dr. Ankur Hastir-MGM Medical College & Hospital, Bombay, India.
BARIATRIC SURGERY
Bariatric surgery: Surgical t/t for morbid obesity
Alteration of metabolic process & durability of weight loss
1st malabsorptive operations was done in 1950
Indications:
a) BMI > 40 or BMI > 35 with co morbid conditions {BMI=Wt / (Ht*2)}
b) Failed dietary therapyc) Psychiatrically stable without
addictionsd) Motivated individualse) Medical problems not precluding
probable survival from surgery
Co-morbid conditions: CVS: HTN, DVT, Pulm. HTN ,
cardiomyopathy Pulmonary: obstructive sleep apnea ,
asthma Metabolic: diabetes , hyperlipidemia GIT: GERD , Cholelithiasis Musculoskeletal: osteoarthritis, ventral
hernias
Co-morbid conditions:
Genitourinary: stress incontinence, end stage renal disease
Gynaecologic: menstrual disturbances Skin: fungal inf., boils, abscess Oncologic: uterus, breast, colon Neurologic: stroke, pseudotumor
cerebri Psychiatric: depression Social: discrimination, abuse
Pre-op investigations: Weight , height , BMI CBC , BT , CT , PT LFT , RFT , blood sugar, lipid profile X – ray chest PFT ECG , 2 D Echo Thyroid profile Insulin levels Serum cortisol
Pre-op investigations:
UGI Endoscopy Barium meal Venous doppler lopwer limbs Ct abdomen
Pre-op preparation: 1st generation cephalosporin– 24 hrs
before surgery Prophylaxis against DVT: 1. subcutaneous heparin 2. early ambulation post op
Operations & Mechanisms: RESTRICTIVE Vertical banded gastro-plasty Lap adjustable gastric banding Sleeve resection
LARGELY RESTRICTIVE/ MILDLY MALABSORPTIVE Roux-en-Y gastric bypass LARGELY MALABSORPTIVE \ MILDLY RESTRICTIVE Bilio-pancreatic diversion
(BPD) Duodenal switch
Sleeve resection
Operative details:
Patient position: Supine, hips flexed at 30 degree & abducted , anti trendelenburg position
Surgeon position: French position Assistant 1st: Right side of pt. Assistant 2nd: Left side of pt.
Operative details: Port placement:
supraumblical- 10 mm optical portRt. subcostal- 12 mm retracting portLt. subcostal- 05 mm retracting portRt. umbilical- 05 mm working portLt umbilical- 10 mm working port
Resected specimen:
Greater curvature
Fundus (upper end)
Body pylorus junction(Lower end)
Postoperative care: Appropriate fluid resuscitation Foleys catheter – 24 hrs Adequate analgesia DVT proohylaxis GIT radiographic study Dietary management Long term follow up
Lap adjustable gastric banding
ADVANTAGES:
1. Short duration op2. Early discharge3. Flexibility4. Resolving of comorbid conditions:
DM, HTN, dyslipidemia , GERD ,
DISADVANTAGES:
1. Band slippage2. Erosion3. Port access site problems4. Leakage of access tubing5. Kinking of the tubing
Roux-en-Y gastric bypass
DISADVANTAGES:
1. Anastomotic leak2. Bowel obstruction3. Stenosis of GJ4. Marginal ulcer at GJ5. Dumping syndrome & dehydration6. Iron & vit b12 def
Bilio pancreatic diversion
DISADVANTAGES:
Protein malnutrition1. Abdominal bloating2. Elevated parathyroid hormone levels3. Bone pains4. Iron & vitamin def5. Marginal ulcers
Duodenal switch
DISADVANTAGES:
1. Same as BPD2. 2 stage operation