Patient selection and

choosing the optional procedure in bariatric surgery

A.R khalaj M.D Minimal Invasive Surgery

Research Center university of Iran

The rational for weight loss surgery 70% of diabets risk can be attributed to obesity

Prevalene of hypertention in BMI>30 Men:41.9% women:37.8%

prevalence of cholesterol in BMI >30 Men:22% women:27%

• mortality in BMI >30 50-100% • Medical treatment for obesity is met with discouraging results

95% regain in 2 years

Indications of bariatric surgeryBe well-informed and motivatedHave a BMI >40Have acceptable risk for surgeryHave failed previous non-surgical weight lossThe NIH also suggested that adults with a

BMI >35 who have serious comorbidities such as diabetes, sleep apnea, obesity-related cardiomyopathy, or severe joint disease may also be candidates

Contraindications to bariatric surgery untreated major depression or psychosis, binge eating disorders, current drug and alcohol abuse, severe cardiac disease with prohibitive

anesthetic riskssevere coagulopathy inability to comply with nutritional

requirements including life-long vitamin replacement

Bariatric surgery in advanced (above 65) or very young age (under 18) is controversial.

Evaluation of obese patient for bariatric Is he or she well informed and motivated?Dose this patient have any contraindications to

weight loss surgery?Will this patient be able to tolerate general

anesthesia?Are there any medical conditions that would make

one operation better suited?Will this patient be able to tolerate the most

common complications?What is dietary history of the patient?Is psychologic evaluation important?

Buchwald algorithm for patient selectionThere is no gold standard operation .A surgeon should be able to perform more

than one operation.Patient can be matched to a specific

procedure

Operation of choice for a patient :

Patients dietary and psychology historyMedical and surgical historySurgeon experiencePatient comfort and expectationAbility of medical facility to handle most known

complications

Roux-en-Y gastric bypass (RYGB)

Gastric bypassBest candidates:DiabeticsBMI<50Single

Bad candidates:NoncomplianceWho must take NSAIDHigh risk for gastric pathology

Laparoscopic adjustable gastric band (LAGB)

Gastric bandBest candidates:High risk patientsExtremes of agePrior abdominal operationsIBDWhom cannot tolerate malabsorbtion

Bad candidates:Not able to participate in follow-upHiatal herniaSuper morbid obeseUnwilling to make lifestyle change

Biliopancreatic diversion

Biliopancreatic diversion with duodenal switch

Biliopancreatic diversion with duodenal switch

BPD/DSBest candidates:BMI>50High risk for Gastric pathology

Bad candidates:High operative riskNoncompliant