Clinical update: bariatricClinical update: bariatric surgerysurgeryby by Michael KorenkovMichael Korenkov and and Stefan Stefan

SauerlandSauerlandArticle Adaptation presented by: Tami Hedglin, Article Adaptation presented by: Tami Hedglin,

R.N.R.N.

Definitions for you to Definitions for you to knowknow

Bariatrics-a branch of medicine that deals with the Bariatrics-a branch of medicine that deals with the control and treatment of obesity and allied diseases. control and treatment of obesity and allied diseases.

Diabetes Mellitus-a disorder of carbohydrate Diabetes Mellitus-a disorder of carbohydrate metabolism, usually occurring in genetically metabolism, usually occurring in genetically predisposed individuals, characterized by inadequate predisposed individuals, characterized by inadequate production or utilization of insulin and resulting in production or utilization of insulin and resulting in excessive amounts of glucose in the blood and urine. excessive amounts of glucose in the blood and urine.

Hypertension- a common disorder in which blood Hypertension- a common disorder in which blood pressure remains abnormally high (a reading of pressure remains abnormally high (a reading of 140/90 mm Hg or greater.140/90 mm Hg or greater.

Cardiomyopathy-Any of various structural or functional Cardiomyopathy-Any of various structural or functional abnormalities of the cardiac muscle, usually abnormalities of the cardiac muscle, usually characterized by loss of muscle efficiency and characterized by loss of muscle efficiency and sometimes heart failure. sometimes heart failure.

More definitionsMore definitions

Sleep apnea- A temporary suspension of breathing Sleep apnea- A temporary suspension of breathing occurring repeatedly during sleep that often affects occurring repeatedly during sleep that often affects overweight people or those having an obstruction in overweight people or those having an obstruction in the breathing tract. the breathing tract.

Asthma- A common inflammatory disease of the Asthma- A common inflammatory disease of the lungs characterized by episodic airway obstruction.lungs characterized by episodic airway obstruction.

Osteoarthritis-A form of arthritis that is characterized Osteoarthritis-A form of arthritis that is characterized by chronic degeneration of the cartilage of the joints. by chronic degeneration of the cartilage of the joints. Also called Also called degenerative joint diseasedegenerative joint disease. .

Hyperlipidemia- An excess of fats or lipids in the Hyperlipidemia- An excess of fats or lipids in the blood. blood.

Is there a need for bariatric Is there a need for bariatric surgery?surgery?

Studies shows that surgically induced Studies shows that surgically induced weight loss provides a survival benefit for weight loss provides a survival benefit for morbidly obese patients. morbidly obese patients.

In two recent cohort studies, bariatric In two recent cohort studies, bariatric surgery was compared with conservative surgery was compared with conservative weight-loss management.weight-loss management. reduced long-term mortality in morbidly obese reduced long-term mortality in morbidly obese

patientspatients

The decrease in mortality rates in the two The decrease in mortality rates in the two studies amounted to 29% and 40%, studies amounted to 29% and 40%, respectively. respectively.

Are you a candidate for Are you a candidate for surgery?surgery?

Bariatric surgery is appropriate for Bariatric surgery is appropriate for adult patients with a body-mass index adult patients with a body-mass index (BMI) of 35 kg/m and over with (BMI) of 35 kg/m and over with obesity related co morbidities. These obesity related co morbidities. These includeinclude type 2 diabetes mellitustype 2 diabetes mellitus hypertensionhypertension cardiomyopathycardiomyopathy sleep apneasleep apnea asthmaasthma osteoarthritisosteoarthritis hyperlipidaemiahyperlipidaemia

Contraindications for Contraindications for surgerysurgery

those with severe mental or cognitive those with severe mental or cognitive retardation retardation

those who will not comply with follow-up those who will not comply with follow-up requirements requirements

those with psychiatric disorders such as:those with psychiatric disorders such as: psychotic, personality, or affective disorderspsychotic, personality, or affective disorders alcoholismalcoholism drug abusedrug abuse

However, preoperative evaluation However, preoperative evaluation sometimes requires consultation by a sometimes requires consultation by a psychiatrist and nutritionist.psychiatrist and nutritionist.

Types of Bariatric Types of Bariatric surgerysurgery

Two categories of Bariatric proceduresTwo categories of Bariatric procedures those that reduce food intake (ie, gastric those that reduce food intake (ie, gastric

restriction)restriction) those that reduce food uptake from the those that reduce food uptake from the

digestive tract (ie, malabsorption). digestive tract (ie, malabsorption). The two most common procedures The two most common procedures

worldwideworldwide laparoscopic adjustable gastric bandinglaparoscopic adjustable gastric banding Roux-en-Y gastric bypassRoux-en-Y gastric bypass

done through open approach done through open approach done laparoscopicallydone laparoscopically

Lap bandingLap banding

band is placed around the upper third band is placed around the upper third portion of the stomach to create a portion of the stomach to create a small stomach pouch small stomach pouch

initially holds 2 ounces of food, and initially holds 2 ounces of food, and eventually holds up to 4 to 6 ounceseventually holds up to 4 to 6 ounces

causes a longer lasting feeling of causes a longer lasting feeling of fullness fullness

works by slowly allowing the food you works by slowly allowing the food you eat to be released into the lower eat to be released into the lower portion of the stomach for digestion. portion of the stomach for digestion.

Lap bandingLap banding

Roux-en-y gastric bypassRoux-en-y gastric bypass

The Roux-en-Y gastric bypass The Roux-en-Y gastric bypass procedure involves creating a procedure involves creating a stomach pouch out of a small portion stomach pouch out of a small portion of the stomach and attaching it of the stomach and attaching it directly to the small intestine, directly to the small intestine, bypassing a large part of the stomach bypassing a large part of the stomach and duodenum.and duodenum.

Not only is the stomach pouch too Not only is the stomach pouch too small to hold large amounts of food, small to hold large amounts of food, but by skipping the duodenum, fat but by skipping the duodenum, fat absorption is substantially reduced. absorption is substantially reduced.

Roux-en-Y gastric bypassRoux-en-Y gastric bypass

Biliopancreatic diversion Biliopancreatic diversion

In a biliopancreatic In a biliopancreatic diversion, a portion of the diversion, a portion of the stomach is stomach is removedremoved. The . The remaining portion of the remaining portion of the stomach is connected to stomach is connected to the lower portion of the the lower portion of the small intestine.small intestine.

Biliopancreatic diversion Biliopancreatic diversion

biliopancreatic diversion biliopancreatic diversion with duodenal switch with duodenal switch

In a biliopancreatic diversion with In a biliopancreatic diversion with duodenal switch, a smaller duodenal switch, a smaller portion of the stomach is portion of the stomach is removed, but the remaining removed, but the remaining stomach remains attached to the stomach remains attached to the duodenum (the upper part of the duodenum (the upper part of the small intestine). The duodenum small intestine). The duodenum is connected to the lower part of is connected to the lower part of the small intestine. the small intestine.

biliopancreatic diversion biliopancreatic diversion with duodenal switch with duodenal switch

Roux-en-Y Roux-en-Y bypass/biliopancreatic bypass/biliopancreatic

diversiondiversion greater potential for serious greater potential for serious

perioperative complications, including perioperative complications, including lethality and malnutritionlethality and malnutrition

associated with better long-term associated with better long-term outcome in terms of weight loss outcome in terms of weight loss

requires less dietary restrictionsrequires less dietary restrictions appears to be more effective than appears to be more effective than

both standard Roux-en-Y method and both standard Roux-en-Y method and laparoscopic adjustable gastric laparoscopic adjustable gastric banding in terms of weight lossbanding in terms of weight loss

Complications of Roux en Y Complications of Roux en Y /biliopancreatic diversion/biliopancreatic diversion

leakageleakage stoma stenosisstoma stenosis gastric distensiongastric distension gastrointestinal hemorrhagegastrointestinal hemorrhage small-bowel obstructionsmall-bowel obstruction gastrojejunal ulcers gastrojejunal ulcers nutritional deficienciesnutritional deficiencies inadequate weight lossinadequate weight loss

Lap sleeve gastrectomyLap sleeve gastrectomy

Laparoscopic sleeve gastrectomy can be Laparoscopic sleeve gastrectomy can be done as an initial weight-loss procedure done as an initial weight-loss procedure followed by second-stage duodenal switch followed by second-stage duodenal switch for high-risk patients or in addition to gastric for high-risk patients or in addition to gastric banding when weight loss is insufficient. banding when weight loss is insufficient.

Biggest drawback of this procedure is the Biggest drawback of this procedure is the potential for sleeve dilatation, resulting in a potential for sleeve dilatation, resulting in a stop in weight loss or even a gain. stop in weight loss or even a gain.

Can be used as a stand-alone bariatric Can be used as a stand-alone bariatric procedure for some special groups of high-procedure for some special groups of high-risk patients.risk patients.

Lap sleeve gastrectomyLap sleeve gastrectomy

Which is safest?Which is safest?

In accordance with current opinion, laparoscopic In accordance with current opinion, laparoscopic adjustable gastric banding is generally considered to adjustable gastric banding is generally considered to be the safest and quickest, but the long-term outcome be the safest and quickest, but the long-term outcome and quality of life, especially for eating patterns, have and quality of life, especially for eating patterns, have been questioned.been questioned.

Band-related complications include band slippage, Band-related complications include band slippage, leak, intolerance, infection, and migration, as well as leak, intolerance, infection, and migration, as well as insufficient weight loss. insufficient weight loss.

The management of these complications includes:The management of these complications includes: band replacement for slippage band replacement for slippage band removal for infectionband removal for infection band removal plus Roux en-Y gastric bypass for band removal plus Roux en-Y gastric bypass for

intoleranceintolerance band in situ plus sleeve gastrectomy for insufficient band in situ plus sleeve gastrectomy for insufficient

weight lossweight loss addition of biliopancreatic diversion or band removal plus addition of biliopancreatic diversion or band removal plus

the Roux-en-Y technique for insufficient weight lossthe Roux-en-Y technique for insufficient weight loss

How to choose?How to choose?

choice of surgical procedure partly depends on the choice of surgical procedure partly depends on the repertoire of the surgeonrepertoire of the surgeon

most surgical centers cannot offer the full range of most surgical centers cannot offer the full range of possible operations. possible operations.

Some centers prefer Roux-en-Y gastric bypass or Some centers prefer Roux-en-Y gastric bypass or biliopancreatic diversion, while others have biliopancreatic diversion, while others have nominated laparoscopic adjustable gastric banding nominated laparoscopic adjustable gastric banding or laparoscopic sleeve gastrectomy as their first-or laparoscopic sleeve gastrectomy as their first-choice procedure and do the Roux-en-Y technique or choice procedure and do the Roux-en-Y technique or biliopancreatic diversion only when the laparoscopic biliopancreatic diversion only when the laparoscopic procedure has failed. procedure has failed.

On the balance between risks and benefits, patients On the balance between risks and benefits, patients with more severe obesity ( BMI>50) are generally with more severe obesity ( BMI>50) are generally considered good candidates for Roux-en-Y bypass or considered good candidates for Roux-en-Y bypass or biliopancreatic diversion, whereas adjustable gastric biliopancreatic diversion, whereas adjustable gastric banding or sleeve gastrectomy may be more banding or sleeve gastrectomy may be more appropriate in milder degrees of obesity.appropriate in milder degrees of obesity.

Further findings…Further findings…

The effectiveness of obesity surgery has been The effectiveness of obesity surgery has been traditionally measured only in terms of excess weight traditionally measured only in terms of excess weight loss, for which data clearly indicate the effectiveness of loss, for which data clearly indicate the effectiveness of all procedures.all procedures.

Today, research emphasis is more on the effect of Today, research emphasis is more on the effect of surgery on obesity-related comorbidites, which can surgery on obesity-related comorbidites, which can affect metabolic, cardiovascular, respiratory, affect metabolic, cardiovascular, respiratory, gastrointestinal, musculoskeletal, and urological organ gastrointestinal, musculoskeletal, and urological organ systems. systems.

Additionally, the psychological benefits of weight loss Additionally, the psychological benefits of weight loss are being investigated. New data indicate that at least are being investigated. New data indicate that at least some bariatric procedures exert their beneficial some bariatric procedures exert their beneficial metabolic effects not only by weight loss but also metabolic effects not only by weight loss but also through a change in hormone release (ghrelin, peptide through a change in hormone release (ghrelin, peptide YY, and glucagon-like peptide 1) from the gut.YY, and glucagon-like peptide 1) from the gut.

This finding corresponds to clinical observations that This finding corresponds to clinical observations that obesity in patients with diabetes is especially amenable obesity in patients with diabetes is especially amenable to bariatric surgery.to bariatric surgery.

Remember!Remember!

As can be expected from other As can be expected from other surgical disciplines, the results of surgical disciplines, the results of surgery critically depend on the surgery critically depend on the expertise of the surgeon and the expertise of the surgeon and the multidisciplinary team.multidisciplinary team.

Mortality in high-volume centers Mortality in high-volume centers is lower than in lower-volume is lower than in lower-volume centers.centers.

In conclusionIn conclusion

There is good evidence to show There is good evidence to show that bariatric surgery is more that bariatric surgery is more effective than non-surgical effective than non-surgical approaches in the therapy of approaches in the therapy of morbid obesity.morbid obesity.

However, no single operation is However, no single operation is ideal for every morbidly obese ideal for every morbidly obese patient, and all operations also patient, and all operations also entail some disadvantages.entail some disadvantages.

References:References:

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