th

Conference & Live Workshop onBARIATRIC & METABOLIC SURGERY

International

“ASIAN SUMMIT”Recommendations thro' evidence

Date : Nov 20th & 21st, 2015 | Venue : WESTIN, Chennai, India

Bariatric SurgeryPractice GuideBariatric SurgeryPractice Guide

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FOREWORD

Welcome to LAPAROFIT again, India's most popular bariatric surgical program!

Over the past few decades there has been enormous progress in the field of bariatric and metabolic surgery

spurred by the obesity and diabetes epidemic. A large body of evidence has been generated over this time to

cater the increasing need among bariatric surgeons and physicians to provide safe and effective treatment.

However the numerous innovations and wide spectrum of application have led to the persistent problem of

clinical dilemmas and significant practice variation.

The concept of evidence-based medicine is to allow the conscientious, explicit, and judicious use of current

best evidence in making decisions about the care of individual patients. In this year‟s conference our

scientific committee and faculty did the work of sifting through the scientific literature to offer sequenced

practice guidelines. These guidelines, incorporated in this summary, have been based on the best available

evidence and is aimed at everyday decision-making situations.

Each and every session of the conference is planned in such a manner that the speaker and the participants

will discuss the collected evidences in detail during the sessions. We aim to discuss this thoroughly during

the conference to reach a consensus on state-of-the-art management pathways to guide practicing bariatric

physicians and surgeons.

These practice guidelines are meant to serve as a resource to our attending delegates and will provide a

snapshot to our upcoming „Bariatric surgery practice guide‟ textbook planned to have chapters that reflect

the current state of the evidence and practical management strategies.

This effort we believe would make bariatric practice more streamlined and organized, as India continues in

its march towards leadership in bariatric surgery.

Dr.P.Praveen Raj, Organizing Secretary

Laparofit 2015

SELECTION OF A PATIENT

SELECTION OF A PATIENT

Guidelines

The BMI criterion for bariatric surgery as proposed in 1991 by the National Institute of Health was

widely adopted worldwide. It worked well at that time as the primary objective of bariatric surgery

was the relief of severe obesity.

In the following decades, results from clinical series worldwide showed that bariatric surgery not

only induced a significant weight loss but also led to a full remission of comorbidities such as

T2DM, cardiovascular and pulmonary diseases, infertility, hyperlipidemia etc

With time studies showed that regardless of BMI, complete or partial remission of T2DM is possible

and these results mostly occur before weight loss, positioning metabolic surgery as a good tool for

controlling the current T2DM epidemic.

The NIH consensus statement 1991 is now more than 20 years old and was based upon data accrued

even before this time. There is a need to use newer bariatric/ metabolic surgery guidelines.

Issue of BMI

BMI was developed as an objective easy method to measure adiposity and was quickly adopted

worldwide as the main criterion for bariatric surgery.

But by not taking into account other parameters such as race, gender, age and fat distribution, BMI

criteria excluded many patients who could benefit from bariatric surgery

BMI is not a good tool to choose the best treatment option for bariatric and/or metabolic surgery.

Clinical endocrinologists/diabetologists should have a role in the perioperative decision-making for

patients undergoing bariatric surgery.

Contraindications to Metabolic and Bariatric Surgery

Patients at prohibitive operative risk should not be offered surgery.

Patients with limited life expectancy due to irreversible cardiopulmonary or other end-organ failure

or metastatic or inoperable malignancy.

Patients pregnant or who expect to be pregnant within 12 months of surgery should be deferred.

Impaired intellectual capacity or the inability to comprehend the surgical intervention or the lifelong

behavior changes necessary to ensure success and safety.

Patients not able, willing, and motivated to comply with postoperative lifestyle changes, dietary

supplementation, and follow-up.

Active drug, alcohol abuse and untreated severe psychiatric illness.

Evaluation process

Cardiac/Diabetes/VTE Evaluation/OSA and OHS evaluation/UGI scopy/ Psychological Evaluation

PREDICTORS OF OUTCOMES

(exception of DM)

PREDICTORS OF OUTCOMES (exception of DM)

Preoperative predictive factors for postoperative weight loss

Considerable effort has been made in the recent years, in order to identify specific preoperative predictive

factors in obese patients which may alter the degree of weight loss postoperatively.

The only factor which has been subjected to meta-analysis is that of preoperative weight loss which shows a

positive association with postoperative weight loss following bypass surgery.

Another clinical variable is baseline BMI; the higher the BMI, the more likely the patient will lose less of a

percentage of excess body weight relative to patients with lower initial BMIs. This effect is in part an artifact

of measuring weight loss in relative rather than absolute terms.

Although the remaining data are not based on level 1 evidence other preoperatively identifiable factors

which are associated with an improved outcome include Caucasian ethnicity, higher educational status, non-

shift-work working patterns, female gender and divorced or single marital status.

Similarly increased levels of preoperative physical activity and an absence of binge eating behaviour are

consistent with a favourable result whereas increased age, smoking and other socioeconomic factors have not

been shown to have a significant impact.

Conversely diabetes mellitus seems to have a slight negative correlation with postoperative weight loss;

however, a history of psychiatric illness has not been shown to have a lasting influence.

Selection of procedure:

1) Anaemia and bariatric surgery:

Pre-operative deficiency of Iron, Folic acid and Vitamin B12 has been the major predicting factor for

post- operative deficiencies. Hence identification and appropriate correction is important.

Following bariatric surgery this is further aggravated by reduced intake, altered gastric pH and

malabsorption.

Identification and appropriate management is crucial. This requires pre-surgery correction and

appropriate follow up.

Significantly malabsorptive procedures like BPD/BPD-DS have reported the highest incidences.

Among RYGB/LSG , the chances of post-operative deficiency and chances of developing anaemia

are equal except that the chances of vitamin B12 deficiency is higher with LRYGB.

Considering the high incidence of anaemia in spite of regular prescription as per the existing

guidelines , more intense follow up and management is necessary

The absorption of oral iron is unreliable and IV iron can restore the iron status more reliably.

2) Bone mineral density and bariatric surgery :

A significant reduction of bone mineral density has been noted after bariatric surgery and this

reduction is associated with change in body composition

This reduction starts immediately and hence replacements should be initiated in the earlier months It

is also interesting to note that the fall may continue even beyond 1 year after the weight loss has

stabilized.

The fall is more significant in femoral neck and not spine But it is controversial whether this fall is

related to increased incidence of fracture.

Pre-operative loading, ongoing vitamin D and calcium supplementation , protein replacement and

exercises decelerates the reduction of bone mineral density

Pre-operative evaluation and correction if any deficiency present is most important

Since this is documented even with adequate replacements based on current recommendations,

current recommendations need alteration.

The incidences have been more significant in malabsorptive procedures like bilio-pancreatic

diversion.

Although this has been documented both with LSG and LRYGB , no difference between the two

groups have been noted.

3) Bariatric surgery and dyslipidemia :

Bariatric surgery has been very effective in the treatment of all components of metabolic syndrome

including dyslipidemia.

Intestinal malabsorption has a significant role in improving the parameters of dyslipidemia. Hence

malabsorptive procedures like BPD/BPD-DS have the best outcomes but at the cost of more severe

nutritional effects. The improvements in LAGB have been closely related to the weight loss.

Amongst LSG and LRYGB, LSG has significant improvements in reducing triglycerides and

improving HDL, but not in reducing total cholesterol and LDL levels.

4) Bariatric surgery and elderly :

Age has been considered as an important predicting factor for the outcomes of bariatric surgery

Although there were concerns of increasing morbidity and mortality in the past , recent reports have

proved its safe even in the elderly.

Bariatric surgery in these patients may be associated with increased hospital stay , but has proven to

be very effective procedure in the long-term.

But the overall results may be inferior compared to younger individuals.

Both LSG/LRYGB have proven to be a safe and effective procedure in these patients .

5) Super obesity and bariatric surgery :

Compared to RYGB , malabsorptive procedures like BPD/BPD-DS have shown better results but at

the expense of more nutritional deficiencies.

RYGB has shown significantly better weight loss compared to LSG.

LSG is effective as a single stage procedure but with the possibility of second procedure in 50% of

patients. In patients with >70 BMI , staged procedures are better

In RYGB , longer alimentary limb bypass has shown better outcomes compared to shorter limbs.

Laparoscopic adjustable gastric banding has not shown good results

PREDICTORS FOR

TYPE II DIABETES MELLITUS REMISSION

AFTER METABOLIC/BARIATRIC SURGERY

PREDICTORS FOR TYPE II DIABETES MELLITUS REMISSION AFTER METABOLIC AND

BARIATRIC SURGERY

Predictors for type II diabetes mellitus remission

The worldwide rapidly increasing prevalence of obesity and type II diabetes mellitus (T2DM) poses a major

threat to health and represents an economic burden in every country. An unexpected potential cure for

T2DM is bariatric/metabolic surgery. It is generally accepted that this kind of surgery provides significant

and lasting weight loss as well as T2DM remission for obese patients with type 2 diabetes mellitus (T2DM).

The rate of complete remission (so-called “cure”) of T2DM was approximately 78.1% in a meta-analysis by

Buchwald et al., 62-83% at a 2 to 4-year follow-up in a systemic review by Meijer et al., and 82.9% at a 10

to 14-year follow-up in a case series by Pories et al. However, not all patients achieve complete remission or

marked improvement of T2DM.

The predictors were significantly different between low and high BMI groups except duration of T2DM. In

the high BMI group, the priority of predictors for T2DM remission were duration of T2DM, insulin use, age,

C-peptide, HbA1c, BMI, and beta-cell function. In the low BMI group, the priority of predictors for T2DM

remission was beta-cell function, duration of T2DM, BMI, and C-peptide.

1) Duration of T2DM

Since it was reported in the historical landmark article by Pories WJ et. al. disease duration has been

consistently recognized as an important predictor of T2DM remission after surgery. Patients with a

shorter duration of T2DM will have a greater remission rate after surgery, indicating that earlier surgical

intervention equates to better outcomes or the preventing the development of DM

2) Pre-operative Insulin use

Insulin usage was prescribed when the residual beta-cell reserve could not provide enough insulin to

overcome hyperglycemia and stabilize plasma glucose level.Patients with T2DM treated with insulin

have more severe T2DM and poorer baselines, thus decreasing the DM remission rate.

3) Pre-operative C-peptide

C-peptide is a connecting peptide to insulin and represents the capacity of insulin secretion.C-peptide

levels in T2DM patients may reflect pancreas preservation, and measuring these levels is a valuable test

to classify the diabetes stage.C-peptide was also confirmed to be an independent predictor of T2DM

remission by multivariate analyses in recent studies.A greater C-peptide level correlates to a better

remission rate in T2DM patients after surgery.

4) Age

Age is consistently recognized as an independent predictor of T2DM remission. Age may represent the

general reserve of physiological and beta-cell function, both of which gradually decline with age

[UKPDS data] because of decreased cell mass and a poorer beta-cell functional reserve.Younger T2DM

patients had better T2DM remission rates after surgery.

5) Pre-operative HbA1c

HbA1c is used as the standard DM definition and indicates the severity of T2DM. Greater HbA1c levels

indicate higher insulin resistance or lower beta-cell function. Lower HbA1c levels equate to a greater

possibility of T2DM remission after surgery.

6) Pre-operative BMI (body mass index)

The real role BMI deserved a detail study in the future. Based on the strong relationship between

obesity and T2DM, a reduction of body weight may accelerate the speed of T2DM remission . Although

BMI is not been proven to be a preoperative factor yet, relatively high initial BMI provides more capacity to

reduce body weight, which may have a greater effect on T2DM remission .

7) The Choice of the Procedure

The final factor considered was the type of surgical procedure. Many studies found that bypass surgery

might have a better T2DM remission rates than other restrictive procedures, such as adjustable gastric

banding or sleeve gastrectomy, based on multivariate analyses. The superiority of a specific bypass

procedure might be based on a greater weight loss rather than a different physiologic mechanism (BPD >

RYGB/SAGB > SG > ABG). It has also been noted that in patients with poor beta cell reserve indicated by

low levels of stimulated C peptide , bypass procedures have better resolution compared to sleeve

gastrectomy.

Choice of surgery

The choice of metabolic surgery requires precise assessment of risk versus benefit for each operation and

must be individualized for each surgical candidate.

Factors to consider when choosing a metabolic procedure :

• Expertise and experience in bariatric surgical procedures

• The patient‟s preference (when the range of risks and benefits, the importance of compliance, and the

effects on eating choices and behaviors have been fully described)

• The patient‟s general health and risk factors associated with high perioperative morbidity and mortality

• The simplicity and reversibility of a procedure

• The duration of T2DM and the degree of apparent residual beta cell function

• The follow-up regimen for the procedure and the commitment of the patient to adhere to it

Novel metabolic procedures and devices

Several novel procedures and devices, aimed to treat T2DM and not to reduce weight, have been developed

in recent years.Their clinical use should still be considered investigational.

Duodenal - jejunal bypass (DJB) is a stomach-sparing bypass of the proximal intestine that has comparable

limb lengths to the standard RYGB . The foregut and hindgut hypotheses have been proposed to explain its

antidiabetic effects. Since the residual stomach is available for endoscopic examination, it may be considered

a good alternative to RYGB in high-risk groups for gastric cancer.In ileal interposition (IT), a small segment

of terminal ileum, with intact mesentery and neurovascular supply, isinserted into the proximal jejunum,

enhancing its exposure to ingested nutrients. This procedure exaggerates release of incretin hormones

without any weight loss effect. DJB and IT may be combined with conventional SG in order to add the

beneficial effects of the latter procedure

.Laparoscopic gastric plication, laparoscopic adjustable gastric banded plication and endoscopically placed

endoluminal liners are also novel procedures and their effect on glycemic control has yet to be clearly

defined.

Low BMI surgery

Existing cutoffs which exclude class I obesity from bariatric surgery/metabolic surgery were set arbitrarily

20 years ago and there is need to update these recommendations based on available data.

Published literature on bariatric surgery in class I obesity is small but the following can be inferred

1. The effect of class I obesity in the pathogenesis of obesity related co-morbidities has been

confirmed. It leads to shortened life expectancy and worse quality of life as in the more severely

obese.

2. Majority of patients have poor maintenance of weight loss by non-surgical methods over time.

However a small proportion of patients achieve a significant and durable weight loss with non-

surgical treatment.

3. Bariatric surgery class I obesity is a highly effective weight loss strategy at least in the medium term.

Adverse events appear to be the same as patients with morbid obesity. Long term nutritional

problems should be more of concern.

4. Metabolic surgery in class I obesity is associated with significant improvement in glycemic control

and higher remission rates in comparison to standard or intensive medical therapy in diabetics <35

kg/m2.

5. Beneficial effect after metabolic surgery in class I obesity is more likely to occur in those who have

significant beta cell functional reserve as demonstrated by responsiveness to therapy.

6. Magnitude of improvement of diabetes does appear to be less in those with lower BMI compared to

those with higher BMI. Lower the BMI less responsive the diabetes will be to bariatric surgery.

7. Long term data is deficient but shows recurrence with increasing lengths of time after surgery based

on the fact that bariatric surgery slows down the beta cell decline over time but does not stop it.

8. Choice of surgery significantly influences outcome in metabolic surgery for class I obesity. BPD has

the most profound effect on diabetes but caution is adviced in view of surgical risk and severe

nutritional risk. RYGB is superior to sleeve and both are superior to LAGB.

In summary bariatric surgery/metabolic surgery in patients with class I obesity should be considered only

after failure of proper non-surgical therapy/conservative treatment. If metabolic surgery is to be applied

RYGB would be currently the best and safest option and should be done in the presence of preserved beta

cell function.

SURGICAL TECHNIQUE OF SLEEVE AND

ROUX EN Y BYPASS

SLEEVE TECHNIQUE

The surgical technique of laparoscopic sleeve gastrectomy has not been fully standardized yet and there are

still numerous technical controversies.

Following data regarding sleeve technique exists in literature

Results in literature regarding excess weight loss according to size of bougie are controversial but

most results are in favor of the more restrictive groups. However there is an inverse relation between

the size of the bougie and the rate of leaks. Use of size 32-36 Fr as adviced by the sleeve consensus

meeting may decrease leak without impacting excess weight loss.

Another controversial point, is the distance from the pylorus at which gastric division begins. Most

authors begin the section at 4-5 cm from the pylorus, with the aim of improving gastric emptying by

preservation of part of the antrum from the earlier concept of preserving 6-7 cms of the entire antrum

.

It is not appropriate to use a less than blue load on any part of sleeve. When using buttressing

materials, never use a less than green load. When resecting the antrum, never use a less than green

load.When performing revision surgery, firings should be green or larger .

It is important to completely mobilize the fundus before transection leaving 1–2 cm of gastric

remnant just at the gastroesophageal junction at proximal resection avoiding the “critical area” of

vascularization in this area.

Staple line reinforcement has been shown in several publications to decrease bleeding and possibly

even reduce leak rates. Overall, oversewing of gastrointestinal staple lines is likely the most

commonly performed method for reinforcement because of “high” cost of buttressing. Oversewing

is least costly but increases surgery time. Studies show it is beneficial when compared to doing

nothing but may not be as efficacious as buttressing.

Existing data on banded sleeve gastrectomy at present suggests that weight loss in the first follow-up

year is not influenced, but the incidence of vomiting is raised after 12 months when patients start to

increase eating volume

ROUX EN Y GASTRIC BYPASS TECHNIQUE

The Roux en Y Gastric Bypass (RYGB) is widely considered the gold standard in bariatric surgery. However

surgeons world over have used different techniques with respect to pouch creation, stoma, limb length,

defect closure and use of band.

The formation of a narrow gastric pouch is an essential part of the restriction of LRYGBP. Pouch

creation should be vertically oriented in order to exclude the fundus which is the most distensible

part of the stomach. First firing during the creation of pouch should begin no more than 5cms distal

to OG junction and volume is then reduced to 30 ml by vertical firing. Further reduction in volume

has not been shown to increase weight loss or improve outcomes.

Three types of anastomosis are commonly performed: hand-sewn , linear-stapled, and circular-

stapled There is no consensus on the technique of choice.Most of the series conclude that all three

techniques are safe for performing GJA in RYGB with similar weight loss outcomes. Use of a 21-

mm circular stapler is associated with higher rates of stricture, and most surgeons prefer the use of

25-mm circular staplers without significant difference in weight loss. Studies have shown weight

loss/complications was comparable when using either linear or circular stapler in GJ

RYGB is primarly constructed based on the alimentary limb. 75-100 cm is the commonly used limb

length. A longer Roux limb (at least 150 cm) may be associated with modest weight loss advantage

in the short term in superobese but is of limited relevance to postoperative weight loss for the non-

superobese patient.The biliopancreatic limb is usually kept short (less than 75 cm).

Given that the three limb lengths (Roux, BP, and common channel) are interdependent (the longer

the Roux limb the shorter the common channel becomes) this modest weight loss benefit described

is likely a reflection of the shortening common channel. Consequently, bariatric surgeons should pay

more attention to the length of the common channel when constructing a gastric bypass especially in

the superobese population where failure rates after conventional gastric bypass are higher.

The incidence of internal hernias with LRYGB is more when compared to open surgery due to

decreased adhesion formation during laparoscopic surgery. With antecolic approaches taking over as

the preferred approach , the incidence of mesocolic hernia (which was otherwise the commonest) has

reduced drastically. The closure of intermesenteric defects has huge impact on the incidence of

internal hernias and the complications associated with it. Closure of the Petersens hernia is

controversial and although decreased the incidence of Petersens hernia, the overall incidence has not

been reduced. The better the closure the better the outcome.

Banded bypass has been increasingly performed with the intent of prevention of pouch dilatation.

Superior weight loss has been shown in banded bypass patients compared to the nonbanded bypass

both in the short and long term.But increasing incidence of vomiting has been noted in this group.

Currently, there is no consensus of opinion on the ring size to be used.

MISCELLANEOUS:

‘NON-ALCOHOLIC FATTY LIVER DISEASE’

‘PREGNANCY AND BARIATRIC SURGERY’

‘POLYCYSTIC OVARIAN DISEASE’

„GASTROESOPHAGEAL REFLUX DISEASE’

„CONCOMITANT HERNIA AND OBESITY’

„GALLSTONE DISEASE’

MISCELLANEOUS

Non Alcoholic Fatty liver disease:

Considerable data exists that surgically induced weight loss improves nonalcoholic fatty liver

disease (NAFLD) in morbidly obese Caucasian patients.

Emerging data in Asia also confirms that surgically induced weight loss improves nonalcoholic fatty

liver in morbidly obese Asian patients.

Very few studies comparing the effects of the various bariatric interventions are present and it is not

clear which intervention may be better.

Majority of studies (considerable studies of RYGB and few studies on AGB, sleeve ,VBG) report a

consistent beneficial effect and even dramatic resolution in liver histologic examination.(steatosis,

inflammation, and fibrosis)

Some studies have reported a few cases of mild worsening or new onset mild inflammation or mild

fibrosis with VBG, RYGB and BPD/DS.

Mechanism of worsening is unclear, but rapid weight loss and subsequent exposure to toxins from

bacterial overgrowth from intestinal diversion, nutritional deficiencies, and protein malnutrition from

malabsorption may play a role.

Bariatric surgery has been shown to be safe in Childs A compensated liver cirrhosis without portal

HT at a high volume centres in small series.

Both sleeve and RYGB have been shown to be safe procedures in cirrhotics in these series. However

restrictive operations are quick procedures and less invasive than a bypass. Most would also not

consider a RYGB because the bypassed stomach will be inaccessible should variceal bleeding

develop especially at the fundus . In case of NAFLD cirrhosis without portal hypertension, a RYGB

may be considered because of benefits to the metabolic syndrome.

Cirrhosis may be an unexpected finding at bariatric surgery in 1 to 2% or patients with hepatic

cirrhosis may present for consideration for bariatric surgery. Can proceed if early cirrhosis, Childs

A, no portal HT if OR if unexpected can take a biopsy and defer if not worked up.

Pregnancy and bariatric surgery:

Pregnancy has to be delayed atleast from 12-18 months after the bariatric surgery

All the health consequences associated with obesity in pregnancy is diminished after bariatric

surgery.

The chance of IUGR has been higher in pregnancies after bariatric surgery

Close supervision and nutrient supplementation before, during and after pregnancy is important to

prevent nutrition related complications

Polycystic ovarian disease:

The pathophysiology is multifactorial and is characteristics any two of the following 1.oligomenorrhea

and/or anovulation 2.clinical and/or biochemical signs of hyperandrogenism 3.polycystic ovaries on imaging

Insulin resistance and secondary hyperinsulinemia is a key feature of PCOD

High LH along with hyperinsulinemia contribute to polycystic ovaries

Many patients with PCOD may not have polycystic ovaries and many patients may not be obese(50-

65% obesity in PCOD),although the clinical manifestations are similar

Endocrinologist opinion to rule out other endocrine disorders is of prime importance before

contemplating for surgery. As these patients have high incidence of impaired glucose tolerance and

type 2 DM, DM profile has to be thoroughly done.

Endometrial aspiration may be considered in above 35 years rule out endometrial carcinoma

Weight loss is the key to improvement of PCOD and also in pregnancy.

Artificial reproductive techniques have also been more successful after weight loss (non-surgical

means and bariatric surgery)

Menstrual abnormalities improve significantly although the improvement of hirsutism is less than

30%

Gastroesophageal reflux disease:

Incidence of GERD in morbidly obese patients is high as obesity itself causes GERD by increasing

the intra-abdominal pressure, causing Hiatus hernia and also by causing mechanical alteration in

esophagogastric junctions

Both anti-reflux surgery and bariatric surgery are equally effective in controlling symptoms of

GERD in morbidly obese patients.

GERD failure rate following bariatric surgery is less than simple anti-reflux surgery as the bariatric

surgery additionally reduces weight & thus reducing the intra-abdominal pressure.Hence bariatric

surgery is more ideal in a morbidly obese GERD patients who requires a surgical management.

RYGB has a better symptomatic control and low recurrence rate than any other bariatric procedures

in treating GERD.

Symptomatic control of GERD following SG is varying. Volume reflux after SG is increased

Sleeve gastrectomy is only a relative contraindication in the presence of GERD. It can be done with

prior counselling and explanation to the patient about the possible recurrence of GERD over a long term

and the issue of unkknown long term consequences of volume reflux.

The incidence of de novo GERD following GERD is between 2 to 21%. De novo GERD incidence

can be reduced by simultaneous HH repair if present and by doing a technically good SG (adequate

posterior fundus mobilisation with complete fundectomy)

In post SG worsening of GERD which does not respond to PPI, ideal choice is to convert to RYGB

which has already proven its efficacy in controlling GERD.

Concomitant hernia and obesity:

Obesity is one of the important predisposing factors for primary/recurrent hernia. It is not uncommon to

encounter obese patients planned for bariatric surgery with simultaneous hernia

Four options exist for management of these patients

1.Hernia first approach

2.Bariatric first approach

3.Concomitant hernia with biological mesh

4.Concomitant repair with composite mesh

Hernia first approach could potentially make future surgery more difficult and the precipitating

factor not being handled

Bariatric first approach without addressing the hernia , may precipitate complications of hernia in in

immediate post op period.If chosen the omental plug in these hernia should not be removed .

With the currently available biological meshes not durable , concomitant repair with composite mesh

can be safely done including gastric bypass and other clean contaminated procedures procedures

(eg:cholecystectomy,hysterectomy )

In patients with undue contamination of the peritoneal cavity , mesh placement can be withheld.

Gallstone disease after bariatric surgery:

Obesity is considered an independent risk factor for gall stones. Incidence of gall stone diseases

increases after bariatric surgery and weight loss of lesser than 25% of initial weight is considered to

be the only predictor for the stone formation.

Probable causes for increased incidence of GSD are rapid weight loss, increased bile cholesterol

saturation, increased gall bladder secretion of mucin and reduced gall bladder mobility due to injury

of the vagus nerve.

Three approaches exist. for cholecystectomy in patients undergoing bariatric surgery

1.Prophylactic approach – Performing Lap Cholecystectomy in all patients at the time of initial

surgery, regardless of the presence (or) absence of gall stones. Even though there are fewer studies

supporting this, not recommended routinely unless for high malabsorptive procedures like BPD / DS

2.Elective / selective approach -- performing simultaneous Lap. Cholecystectomy only in patients

with gall stones diagnosed pre / intra operatively, even if it is asymptomatic, most of the studies are

favoring this.

3.In conventional approach -- UDCA 300mg Bid for 6 months, with regular follow-up of USG

abdomen and pelvis. If the patients developed gall stone disease after RYGB / MGB, Lap

Cholecystectomy is advised at the earliest, where as after sleeve gastrectomy, if gall stone disease

developed, can be followed as other normal patients that Lap Cholecystectomy is advised only if it

is symptomatic one.

POST-OPERATIVE PATHWAYS

POSTOPERATIVE PATHWAYS

Obstructive Sleep Apnea

OSA occurs as a result of narrowing or occlusion of the respiratory tract during sleep. Untreated OSA have

hypoxemia during sleep and eventually over time develop pulmonary hypertension, cardiac arrhythmias and

increased risk of mortality. Bariatric surgery patients with OSA are at risk as anesthetics /narcotics blunt the

protective arousal of hypoxic sleeping patients resulting in profound hypoxia or respiratory arrest. Bariatric

surgery patients with OHS who retain carbon dioxide are at risk for carbon dioxide retension and respiratory

arrest due to carbon dioxide narcosis.

Following data exists for OSA in bariatric surgery patients

OSA is highly prevalent in the morbidly obese patients.

Most appropriate test to evaluate OSA is nocturnal polysomnography (PSG) but as routine PSG is

expensive and inconvenient to use for everyone testing based on preoperative symptoms by clinical

screening tools like STOP BANG questionnaire can be considered.

An echocardiogram should be performed to assess right ventricular function and pulmonary

hypertension.

Patients with documented moderate to severe OSA should be strongly encouraged to accept

treatment preoperatively with continuous positive airway pressure (CPAP).

A period of preoperative adjustment to the device is recommended prior to surgery but no fixed

recommended time for preoperative CPAP exists presently.

Perioperative precautions include prudent airway management by the anaesthetist and OSA

mitigation measures.

Postoperative CPAP and Bi-level PAP can be safely omitted if they are observed in a monitored

setting and their pulmonary status is optimized by aggressive incentive spirometry and early

ambulation.

No strong evidence exists that CPAP may increase the likelihood of an anastomotic leak by air

forced into the gastric pouch thus it can be used if indicated for pulmonary concerns.

There is significant improvement in subjective symptoms of OSA after bariatric surgery but absence

of clinical symptoms does not necessarily correlate with normalization of AHI.

No evidence exists upon which to base recommendations for retesting for OSA following bariatric

surgery. However as the concern is long term effects of untreated OSA surgeons can consider repeat

PSG testing after significant weight loss.

Gastrograffin study

All bariatric surgeries come with an inherent risk of leak. In order to decrease morbidity and mortality

associated with these complications, early detection is critical.

Many institutions do a routine UGI to evaluate for leaks on POD 1 or 2.

For LRYGB and sleeve, several studies specifically show the lack of utility of routine UGI in all

patients. Overall sensitivity for leak is very low.

Most patients who develop leak have a negative initial UGI and require a CT swallow study to

identify the source of the leak. Clinical signs and symptoms consistent with leak prompted the CT

swallow studies.

The lack of sensitivity of the UGI for diagnosis of leak is may be due to the timing of the UGI. These

studies will generally assess technical issues, ie leaks secondary to early mechanical failure but not

the later ischaemic leaks.

Other factors do influence the sensitivity, including the experience of the radiologist, the size of the

leak, the contrast material used.

Thus it can be concluded that the potential benefit of early routine UGI is small compared with the

cost of the study and the low and late incidence of leaks. Thus many suggest abandoning routine

UGI in favor of following patients for development of symptoms.

It may also be concluded that UGI in the early postoperative period is still worth completing due to

its ability to find mechanical defects in the staple line. Some may argue that intra-operative air

test/endoscopy to verify no mechanical defects within the staple line may be sufficient but these are

not foolproof methods.

Other reasons do exist to complete early routine UGI aside from the evaluation for leaks. Early

routine UGI allows for documentation of final operative anatomy. This may help evaluation of

performance, especially for general surgeons in training( being able to visualize internal anatomy

following surgery allows for improvement in surgical skills). Routine UGI will also show any

transient causes of obstruction, such as hematoma or edema within the lumen that would prevent a

patient from tolerating a diet and would change the management of patients in these cases.

DVT prophylaxis

Obesity is both an independent and an additive risk factor for venous thromboembolism (VTE).

Patients undergoing bariatric surgery are considered to be at moderate to high risk for having

thrombotic complications.

VTE is also a leading cause of mortality after bariatric surgery.

In obese and morbidly obese patients on chemical VTE prophylaxis with fixed standard doses peak

anti-FXa levels are often below recommended target anti-FXa levels for VTE prevention. Based on

this knowledge most bariatric surgery units are currently using higher than standard doses of heparin

or LMWH for VTE prophylaxis which however varies from institution to institution.

Enoxaparin is the most studied. Strongest data seem to support the use of 40 mg of enoxaparin SQ

every 12 hours. The use of this dose was shown to decrease the risk of VTE in patients undergoing

bariatric surgery compared to 0.3 mg 12 hourly and when compared to 0.6 mg 12 hourly had

unlikely higher frequency of supraprophylactic doses. However with fixed doses supra-prophylactic

and sub-prophylactic doses are common at extremes of weight(<100 kg and >150 kg).Thus at

weights less than 100 kg standard 0.4 mg once daily dose may be used and above 150 kg 0.6 mg 12

hourly may be used. Safety of weight based dosing in bariatric surgery patients is not known.

Nadroparin at a dose of 5,700 IU /day or Parnaparin at a dose of 4,250 IU/day Dalteparin at a dose of

7,500 IU/day may be used for VTE prophylaxis in bariatric surgery patients based on limited data.

Higher doses of Fondaparinux of 5 mg in severely obese in a bariatric surgical setting may be

required to achieve target anti-FXa levels. However because of the risk of bleeding without

established reversal agent, higher doses should be should be used with caution.

Mechanical methods are often an accompaniment to some form of chemical thromboprophylaxis. It

may be considered if a high bleeding risk precludes the use of pharmacologic prophylaxis in

patients.

The routine use of retrievable IVCF placement in bariatric surgery patients is not supported by the

available evidence. It may reduce postoperative PE, particularly in high-risk bariatric surgery

patients but insertion-related complications have been described and need to be considered.

More aggressively extended prophylaxis should be considered in patients at higher risk for VTE but

there are insufficient data to recommend specific duration. In most series prophylaxis was continued

during hospitalizations, but with earlier discharges from the hospitals prophylaxis most recommend

to continue prophylaxis for a total of 8 to 10 days. Extended pharmacologic thromboprophylaxis for

up to 4 weeks after discharge may be warranted in certain high risk patients undergoing bariatric

surgerybased n extraplated evidence.

POST-OPERATIVE MANAGEMENT

POST-OPERATIVE MANAGEMENT

Diabetes mellitus

Although the remission of type diabetes mellitus and associated comorbidities is clearly understood , the post

bariatric management of these comorbidities has been less clear. The major controversies has been related to

the varied management strategies among various centres with no validated treatment protocol .

The challenge in the post-operative period is to prevent hypoglycemia and also

hyperglycemia(necessary for beta cell regeneration).

Protocol based approach has given outcomes compared to non-protocol based individualized

approaches.

The discharge advise should be based on the sugar levels in the immediate post op period.

Monitor sugars in the immediate post op and manage with Sliding scale insulin/glargine insulin if

needed

If sugars are normal in the post op , no OHA needed

If sugars are high with minimal requirement of insulin , only Metfomin 1 g BD

If the need for Insulin is higher in the post op , discharge with 1g Metformin BD and long acting

insulin based on the post op requirement.

Monitor on a regular basis and titrate accordingly .

HbA1C to be done 3,6 months and 1 year.

Even in patients with compromised beta pancreatic function , significant numbers of patients could

be weaned off insulin .

The durability of T2DM remission has also been closely associated with durable weightloss and

weight maintenance in the longterm.

In patients with non-remission or relapse , weight management along with evaluation of the beta

pancreatic reserve is important.

Management requires a team approach between the surgeon , dietician and diabetologist .

Hypertension

Bariatric surgery has shown significant effects on HT remission.

Management of hypertension requires a good understanding of the procedure and hypertensive

management and requires a team effort between the surgeon and the physician

There has been a drastic reduction in the use of anti-HT after bariatric surgery.

Thiazides are the drugs to be most commonly stopped after the surgery to prevent volume depletion,

hypotension and kidney injury.

For patients with HT and DM , ACE inhibitors and Angiotensin receptor blockers can be safely used

for its renal protective effects.

Beta blockers can be continued for the benefit of perioperative beta blockade.

With regard to dyslipidemia bariatric surgery has shown significant impact on resolution of all

components of dyslipidemia.

Although malabsorptive procedures have significant impact on all parameters , sleeve gastrectomy

has shown lesser impact on total cholesterol and LDL levels.

Statins are good for hypercholesterolemia and fibrates on triglycerides.

NUTRITIONAL MANAGEMENT

NUTRITIONAL MANAGEMENT

Anaemia after bariatric surgery:

Iron deficiency anemia is the most commonly seen deficiency around the world. Post bariatric

surgery patients are at increased risk of iron deficiency anemia in addition to vitamin B12 and folate

deficiency anemia in the immediate post-operative period within 3-6 months irrespective of

restrictive, malabsorptive and combination procedures.

Dietary sources which are rich in these nutrients are less effective in the immediate post-operative

period because of decreased food intake, food intolerance and aversion towards food, reduction of

gastric secretions, bypass of absorption surface area and altered food and drug bioavailability. So,

early supplementation is of prime importantance.

Preoperative deficiency is a major cause for post-surgery deficiencies which indicates the importance

of pre-operative investigations for obese and premenopausal women are at greater risk of anemia in

addition to menstruation status

Based on early literature 40-65mg of iron is the standard supplementation but the absorption of oral

iron is unpredictable /poor. Hence, IV iron is on more successful for patients with severe intolerance

or refractory deficiency but this needs to be done with caution to prevent overload.

Vitamin B12 recommendation after bariatric surgery is 1000mcg which is similar to that of

recommended dietary allowances which can be given through orally or intra-nasally. If these routes

are not sufficient and cannot be maintained intramuscular or subcutaneous route can be used. Folate

recommendation is 400mcg/day after bariatric surgery

Macronutrient protein and bariatric surgery

Protein is essential macronutrient for various processes and is very important for effective weight

loss and to preserve lean mass with improved body composition. In addition it improves blood

pressure, waist circumference, triglycerides and fasting blood glucose levels post surgically

Protein malnutrition after surgery occurs due to lack of adequate intake, food intolerance and food

aversions, socioeconomic status, vomiting and diarrhea.Prolonged period of low protein intake will

lead to reduction of liver proteins, hair loss which can be related to anemia, zinc and thiamine

deficiencies and a compromised immunological capacity which can lead to decreased antioxidant

capacity ending in increased oxidative stress, negative nitrogen balance and deterioration of serum

protein level.

A high protein diet with exercise have been showed to improve the body composition and fat free

mass which is commonly seen after RYGB and BPD.A high protein diet improves the basal

metabolic rate and helps in weight loss and weight maintenance

Recommendation suggests 60-120gms of good quality protein with 30g on each meal to maintain

healthy bones and muscles and protein at breakfast is very important to relieve catabolic state after

overnight fasting and it should be eaten prior to carbohydrate and fat. Vegetarians should consume

cereals and pulses together for the complete protein and traditionally this is being followed in most

of the Asian countries like India

Post surgically patients intake is been drastically reduced for few years and to meet protein needs

dietary supplements should be encouraged to avoid protein malnutrition in long run particularly for

vegans. The role of branched chain amino acids particularly leucine favors the maintenance of

muscle mass plays important role. Leucine is rich in whey protein, casein, egg protein, isolated soy

protein and whey protein.

Pre-operative dietary restriction to bariatric patients

A short term low carbohydrate diet will decrease fat stores and liver volume which is the goal of the

preoperative bariatric diet

Formula based or meal replacement based diet is commonly used but evidence suggests that

compliance to partial use of a formula diet is more effective in preoperative weight loss

80% of expected liver volume is reduced within a 2 week low carbohydrate diet and compliance will

reduce over time

Low carbohydrate diet with 30-130 g of carbohydrate per day have been shoen to result in successful

weight loss

Ketogenic diets with <30grams of carbohydrate per day is also safe but may not be suitable for all

patients

Low carbohydrate diets result in greater weight loss than low fat diets

Micronutrient supplementation is important in this phase to reduce micronutrient deficiencies post

surgery

Additional fluid recommendation of 1 to 3.5 litres should be given based on the type of diet

suggested

Tobacco use should be avoided 6 weeks preoperatively to avoid overall impaired health post

surgically

Post-bariatric surgery diet

Protein is essential macronutrient for various processes and is very important for effective weight

loss and to preserve lean mass with improved body composition. In addition it improves blood

pressure, waist circumference, triglycerides and fasting blood glucose levels post surgically

Protein malnutrition after surgery occurs due to lack of adequate intake, food intolerance and food

aversions, socioeconomic status, vomiting and diarrhea

Prolonged period of low protein intake will lead to reduction of liver proteins, hair loss which can be

related to anemia, zinc and thiamine deficiencies and a compromised immunological capacity which

can lead to decreased antioxidant capacity ending in increased oxidative stress, negative nitrogen

balance and deterioration of serum protein level.

A high protein diet with exercise have been showed to improve the body composition and fat free

mass which is commonly seen after RYGB and BPDA high protein diet improves the basal

metabolic rate and helps in weight loss and weight maintenance

Recommendation suggests 60-120gms of good quality protein with 30g on each meal to maintain

healthy bones and muscles and protein at breakfast is very important to relieve catabolic state after

overnight fasting and it should be eaten prior to carbohydrate and fat

Vegetarians should consume cereals and pulses together for the complete protein and traditionally

this is being followed in most of the Asian countries like India

Post surgically patients intake is been drastically reduced for few years and to meet protein needs

dietary supplements should be encouraged to avoid protein malnutrition in long run particularly for

vegans. The role of branched chain amino acids particularly leucine favors the maintenance of

muscle mass plays important role. Leucine is rich in whey protein, casein, egg protein, isolated soy

protein and whey protein.

SLEEVE LEAK

SLEEVE LEAK

The treatment options for postoperative leaks after bariatric surgery depend on the timing of leaks at

presentation. Currently, there are no clear guidelines regarding optimal leak management.

Following data exists for sleeve leaks in bariatric surgery patients

Leaks can be classified based on the timing of presentation after surgery , imaging and also based on the

location .

Systemic inflammation and peritonitis are usually the main signs for early-onset sleeve leak, whereas

intra-abdominal abscesses and pulmonary symptoms reveal delayed-onset sleeve leaks.

Clinical instability in patients with peritonitis after sleeve leaks justify prompt laparoscopic/open

reintervention for washout and drainage. Simple drainage may only be performed. An alternative

approach to control the leak site is placement of a T-tube directly into the defect or laparoscopic

endoscopic tube drainage through healthy distal antrum. Clinically stable patients with contained

leaks can be drained by percutaneous drainage. These methods require feeding jejunostomy or

nasojejunal tubes to maintain nutrition for prolonged time.

Attempt at early surgical closure of the defect may be performed when re-exploration is early and

tissues are healthy.

Over the last decade, there has been increasing use of self-expanding metal stents (SEMS) for the

treatment of sleeve leaks after drainage. Advantage is that oral feeds can be resumed and it is less

invasive than surgery. Disadvantage is high migration rate and numerous repeat sessions required.

Newer longer stents do not migrate but have problems of distal mucosal ulcerations. Also stenting

alone did not control sepsis in some cases.

More recently, treatment options include the insertion of endobiliary stents. Though they were

described for all cases it has been suggested that stent placement is the primary option for large leaks

and more so if these are associated with sleeve stenosis. For the smaller leaks not accompanied by

stenosis, double pigtail catheters can be used.

Endoscopic therapies such as metal clips, OTSC clips, Glue injection and APC have been described

and can be used as complementary therapy on a case to case basis.

Salvage surgery described include conversion of the sleeve to a regular Roux-Y gastric bypass,

anastomosis of the jejunal Roux limb to the fistula and total gastrectomy

Gastrobronchial fistulas may be treated on the same lines as simple sleeve leak fistula. Need for

thoracotomy with/without lung resection with/without diaphragmatic resection and reconstruction

can be decided on a case to case basis.

REVISION AFTER SLEEVE

GASTRECTOMY

REVISION AFTER SLEEVE GASTRECTOMY

Although Laparoscopic sleeve gastrectomy was initially performed as a first stage procedure for

super obese and high risk patients , it is now been accepted as a standalone procedure.

Like other procedures , revision becomes important with insufficient weight loss,weight regain and

other complications like GERD,strictures etc.

Management options for inadequate weigh tloss and weight regain has not been clearly defined

The success or failure can be expressed in many ways based upon %EWL,BAROS score ,Reinhold

criteria and Biron criteria.

Patients need to be evaluated for patient factors ,technical factors or both.

Correction of patient factors is crucial before planning for surgery.

Evaluation of the sleeve includes understanding the dilatation of the stomach and the residual gastric

volume,

Dilatation can be primary or secondary.

Patients with dilated sleeve defined as a RGV of >250 cc , or with hyperphagia(volume eating) or

endoscopy suggestive of a dilated fundus may benefit from a re-sleeve gastrectomy which has shown

reasonable outcomes. But the overall complication rates have been higher.

LRYGB is the other alternative for the above patients where the results could be similar.Again the

overall complications could be higher.

But in patients without any dilatation,LRYGB or DS are the other options reported.

Malabsorptive procedure like BPD-DS has shown better outcomes compared to LRYGB with the

expense of higher nutritional and surgical complications.

Many other operations have been reported , but only small case reports or series are available ,unable

to arrive at any conclusion

ROUX-EN-Y GASTRIC BYPASS

COMPLICATIONS

ROUX-EN-Y GASTRIC BYPASS COMPLICATIONS

Internal hernia:

The three possible areas are the intermesenteric space,Petersens space and the mesocolic window.

With antecolic approaches taking over as the preferred approach , the incidence of mesocolic

hernia(which was otherwise the commonest) has reduced drastically.

Amongst the mesenteric hernia and the Petersens , which is more commoner is debatable.

The closure of intermesenteric defects has huge impact on the incidence of internal hernias and the

complications associated with it.

Closure of the Petersens hernia is controversial and although decreased the incidence of Petersens

hernia , the overall incidence has not been reduced.

The better the closure the better the outcome .

The presentation can vary from chronic intermittent pain to more acute presentation with gangrene

Even in patients with intestinal obstruction , X ray may not have evident signs of small bowel

obstruction.

With an experienced radiologist CT scan is usually diagnostic. The mesenteric swirl sign is highly

sensitive and specific.

Petersens hernia may have specific signs like clustering of bowel loops behind the Roux limb ,

towards the left ,in front of the ligament of Treitz,with a horizontal course of engorged superior

mesenteric vessels.

High index of suspicion is required and even if imaging is not confirmatory , there needs to be a low

threshold for diagnostic laparoscopy.

The biliopancreatic limb is the commonest limb to herniate and most often in the left to right

direction.

Management of obstructed hernias requires reduction of the herniated bowel and closure of the

defects and can be done successfully by laparoscopy.

Other open defects even if not having any hernia should be closed and this reduces recurrence of

hernia.

Leaks :

The incidence of leaks after gastric bypass is between 0-5.6% and is associated with a high rate of

surgery related mortality.

The gastrojejunal anastamosis followed by the gastric pouch are the commonest areas of leak

Surgical risk factors include anastamotic tension and ischaemia.

Non surgical risk factors include advanced age, super-obesity, multiple co-morbidities and previous

surgeries.

High index of suspicion based on clinical parameters like tachycardia , unusual pain and fever should

prompt further evaluation

Routine UGI series may pick up early leaks but has a high false negative rate.If performed barium is

better than gastrograffin.

CT scans can be confirmatory but related to the experience of the radiologist.

Haemodynamically stable patients can be managed by endoscopic/radiological means with good

success

This includes placing a drain , commencing nutrition(enteral/parenteral) and other support with or

without usage of stenting.

Haemodynamically unstable patients needs surgical intervention and the overall mortality and

hospital stay is expected to be higher.

The overall healing rate is expected to be earlier compared to sleeve leaks.

Marginal ulcer :

The incidence of marginal ulcer has been between 0.6-16% .The incidence of MU s are higher than

expected and the presentation can be varied from being completely asymptomatic to even present

with more severe complications. The first 12 months is when most MU are commonly seen and is

most probably related to the acidity of the gastric pouch

The risk factors can be surgical and nonsurgical

Surgical risk factors are ischaemia, anastamotic tension, large pouch,usage of nonabsorbable suture

materials and antecolic anastomosis. The most important nonsurgical risk factors are smoking and

NSAID usage without PPI.

The role of H.pylori is inconclusive. But is commonly associated with upper GI symptoms , with

eradication having good symptom control. Prophylactic PPI use can be used for 12 months with

longer usage recommended for higher risk patients(Smoking, NSAID usage etc)

Risk/Precipitating factor identification is the key in management of refractory/recurrent MU.

Surgical revision with/without vagotomy can be considered in patients with failure of conservative

management. Patients presenting with perforation , laparoscopic patch closure is ideal in the

emergency setting Revision of the GJ in the emergency has been associated with high morbidity.

GJ stricture:

The incidence of GJ stricture is between 1.6-31% which is usually confirmed by the inability to pass

the gastroscope through the anastamosis.

The risk factors include GERD, younger age, antecolic approach and use of fibrin glue around the

anastamosis

There‟s no difference in the incidence of stricture between the three techniques of

anastamosis(circular vs linear vs hand sewn),except that in circular stapled technique 21mm has

higher rates of stricture.

With no difference in weight loss outcomes between 25mm and 21 mm , 25 mm is preferred if

circular staplers are to be used.

With confirmed stricture , endoscopic dilatation is the first option.TTS(through the scope) balloon is

usually preferred to Savary Gillard dilators

Its better to start from 12 mm dilatation ,although can be gone lower depending upon the stricture.

Although no ideal size exist in literature , 15 mm is more ideal considering the outcomes and

incidence of perforation, although bigger dilatations can be done with caution

Although no specific time for dilatation exist , 1-3 min is preferred. More than one dilatations may

be needed for optimum dilatation .

The outcomes are better with early strictures than late strictures.

Perforations are the commonest complications after dilatations , hence a post dilatation imaging may

be of benefit.

Patients with recurrent strictures after 2 successful dilatations may be treated by a stenostomy using

a needle knife.

Failure of dilatations may require surgical revision of the GJ.

Post RYGB CBD stone :

Prevention is the best management. Post RYGB patients need to be regularly screened for presence

of gasllstones. If present , should be operated at the earliest even if asymptomatic

With the presence of CBD stones , the management options include percutaneous transhepatic

instrumentation of CBD, percutaneous or laparoscopic transgastric ERCP, transenteric ERCP using

specialized endoscopes and lap or open CBD exploration

Amongst all the transgastric gastric approach is prefrred in the background of available experienced

endoscopist. Otherwise open /lap CBD exploration is s suitable option

45, Pankaja Mill Road, Ramanathapuram, Coimbatore, Tamilnadu 641 045 +91 - 90036 88222 laparofit@geminstitute.in

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