Bariatric surgery

1. BARIATRIC
SURGERY

2. Introduction
 Bariatric =Baros: heaviness/large/pressure.
 It is the field of medicine encompassing the study of
obesity, its causes, prevention, and treatment.
 Bariatric surgery: A therapeutic intervention to
understand and treat the cause and sequelae of
morbid obesity.

3. Bariatric Surgery
 Number of procedures performed has increased 10-fold
 14,000 in 1993
 140,000 in 2004
 > 200,000 in 2005
 > 300,000 in 2007

4. introduction
 Obesity is a physiologic
dysfunction of the human
organism with environmental,
genetic, and endocrinologic
causes and a major health
problem with clearly established
health implications

5.  Body mass index (BMI) is a simple index of
weight-for-height that is commonly used to
classify overweight and obesity in adults.
 Defined as a person's weight in kilograms
divided by the square of his height in meters
(kg/m2).

6. Degrees of Obesity
NORMAL
BMI 18.5 – 24.9
OVERWEIGHT
BMI 25 – 29.9
OBESE
BMI 30 – 34.9
SEVERE OBESE
BMI 35 – 39.9
MORBIDLY OBESE
BMI  40

7. Obesity grading and assessment in
Western and Asian Population
BMI
Average
Overweight
Obese
Morbidly
Obese
Western
20-24.9
25-29.9
30-40
>40
Asian
18-22.9
23-27.7
27.5-37.4
>37.5

8. Prevalence of Obesity
 As per WHO’s The World health statistics 2012 report, one in six adults
obese, one in 10 diabetic and one in three has raised blood pressure
 Obesity has reached epidemic proportions in India in the 21st century, with
morbid obesity affecting 5% of the country's population

9. 37.4
53.2
42%
18.0
29.6
65%
55.2
66.2
20%
26.6
51.7
94%
12.1
23.9
98%
58.7
101.0
72%
76.7
112.8
47%
World
2010 = 285 million
2030 = 438 million
Increase 54%
Global projections for the diabetes epidemic:
2010-2030 (millions)
Bariatric Surgical and Procedural Interventions in the Treatment of
Obese Patients with Type 2 Diabetes

10. The Toxic Environment

14. Etiology of Obesity
 Debate is ongoing regarding the relative Genetic Vs Environmental components of the disease.
 Clear familial predisposition.
 Specific Genes: Hundreds of genetic loci have been associated experimentally to obesity in the so-called
Human Obesity Gene Map
1) FTO-Fat mass and Obesity-related gene
2) MC4R-Melanocortin 4 receptor gene
Associated with obesity, increased fat mass and insulin resistance.
 Thrifty Gene Hypothesis: During human development, thrifty gene allowed for more efficient absorption
and use of the calories ingested. However, in modern society ,it helps increase the intake of calories in
excess of metabolic needs.
Role of genes versus environment

15. Pathophysiology Of Obesity
 Obesity can result from increased energy intake, decreased energy expenditure, or a combination
of the two
 The severely obese individual has, in general, persistent hunger that is not satiated by amounts of
food that satisfy the non-obese.
 This lack of satiety or maintenance of satiety may be the single most important factor in the
process.
 Nutrient ingestion into the stomach or proximal intestine elicits hormonal signals that release
neuropeptides, which in turn alter body metabolism.
 Hormones:
 Leptin and Ghrelin are appetite stimulant, orexigenic.
 Insulin and Cholecystokinin are anorexic.

16. Obesity Related Co-Morbidities
Co-Morbidity
◦ Diabetes
◦ Hypertension
◦ Hyperlipidemia
◦ Cardiac disease
◦ Respiratory disease
◦ Obstructive sleep apnea
◦ Arthritis
◦ Depression
◦ Stress Incontinence
◦ Joint problems
Occurrence in the Obese
◦ 14–20%
◦ 25–55%
◦ 35–53%
◦ 10–15%
◦ 10–20%
◦ 20–25%
◦ 70–90%
 50%
 50%

17. Pulmonary disease
abnormal function
obstructive sleep apnea
hypoventilation syndrome
Nonalcoholic fatty liver
disease
steatosis
steatohepatitis
cirrhosis
Coronary heart disease
Diabetes
Dyslipidemia
Hypertension
Gynecologic abnormalities
abnormal menses
infertility
polycystic ovarian syndrome
Osteoarthritis
Skin
Gall bladder disease
Cancer
breast, uterus, cervix
colon, esophagus, pancreas
kidney, prostate
Phlebitis
venous stasis
Gout
Medical Complications of Obesity
Idiopathic intracranial
hypertension
Stroke
Cataracts
Severe pancreatitis

18. What are your options??
Source:Adkinson,AmJ.ClinicalNutrition,1994
1. Diet, Exercise, Behavioral Changes
-up to 10% loss of excess body weight
-ineffective long-term, less than 5% sustain
significant weight loss
2. Weight Loss Drugs
-minimal sustained weight loss
-side effects prevent long-term use
3. Weight-Loss Surgery
-55 to 75% loss of excess body weight

19. Guidelines for the Treatment of Overweight and Obese
Individuals

20. Indications for drug treatment
 Pharmacological treatments are typically used as an
adjunct to diet and exercise for patients with
 BMI of 30 or greater
 BMI of ≥27 for patients with obesity-related risk factors or
comorbid diseases.

21. Obesity Drugs
 Appetite suppressants
 Noradrenergic (Schedule IV)
 Phentermine (Adipex, Fastin)
 Diethylpropion (Tenuate)
 Noradrenergic (Schedule III)
 Benzphetamine (Didrex)
 Phendimetrazine (Bontril)
 Serotonergic
 Fenfluramine, dexfenfluramine
 Mixed Noradrenergic & Serotonergic
 Sibutramine (Meridia)
 Nutrient absorption reducers
 Lipase inhibitor
 Orlistat (Xenical)

22. Sibutramine (Meridia)
 Blocks presynaptic receptor uptake of norepinephrine and serotonin, thereby potentiating
their anorexic effect in the central nervous system
 Contraindicated: CAD, CHF, cardiac arrhythmias or stroke
 Side Effects: hypertension, arrhythmia, tachycardia, headache, dry mouth,
constipation, insomnia

23. Orlistat
 Inhibits pancreatic lipase and thereby reduces absorption of up to 30% of
ingested dietary fat.
 Lipase inhibitor: reduces fat absorption by ~30% resulting in
reduction in energy intake
 Inhibits digestion of dietary triglycerides, decreases absorption of
cholesterol and lipid-soluble vitamins

24. Side Effects
 GI side effects due to inhibition of fat absorption
 pain, fecal urgency, liquid stools, flatulence with discharge, oily spotting

25. Why Diets Often Fail
 Require lot of time and energy
 Cause feelings of deprivation
 Don’t address why people overeat
 Disrupt metabolism

26. Why Surgery?
Diet and exercise are not effective long term
in the morbidly obese
 Surgery is an accepted and effective approach
 Medical co-morbidities are improved/resolved
 Increases life expectancy
 Decreases health care costs
 Surgical risk is acceptable vs. risk of long-term obesity

27. RESOLUTION OF DISEASES FOLLOWING BARIATRIC SURGERY

28. Who Is a Surgical Candidate?
 BMI > 40 kg/m2
-OR-
 BMI > 35 kg/m2 and major medical complications of obesity
-AND-
 Failure of other approaches to long-term weight loss
 Age 18-55(relative)

29. Recommended BMI values for
Bariatric Surgery in Asians
BMI ≥ 37.5
BMI ≥ 32.5
with two
associated
co-
morbidities.

30.  No endocrine cause of obesity
 Acceptable operative risk
 Understands surgery and risks
 Absence of drug or alcohol problem
 No uncontrolled psychological conditions
 Consensus after bariatric team evaluation:
 Surgeon/Dietician/Psychologist/Consultant
 Dedicated to life-style change and follow-up

31. Obesity multidisciplinary team
 Surgeon
 Physician
 Anesthetist
 Dietician
 Specialist bariatric nurse
 Skilled theatre staff
 Psychiatrist

32. Bariatric Surgery and Diabetes
 International Diabetes Federation (2011)
 Journal of Diabetes (3(2011): 261-264)
 “Bariatric surgery is an appropriate treatment of people with T2D and
obesity who are not achieving recommended treatment targets with
existing medical therapies, especially in the presence of other major
comorbidities”
 <1% of those eligible actually have WLS for diabetes

33. Contraindications
 Factors that may be considered contraindications include
◦ unstable CAD
◦ uncontrolled severe OSA
◦ uncontrolled psychiatric disorder
◦ mental retardation (IQ < 60)
◦ inability to understand the surgery
◦ perceived inability to adhere to postoperative restrictions
◦ continued drug abuse
◦ malignancy with a poor 5-year survival prognosis
◦ Cirrhotic liver disease with portal hypertension

34. Preoperative Evaluation
 Attention should focus on issues unique to the obese patient,
particularly cardiorespiratory status and the airway.
 Consideration of co morbidities i.e. hypertension, diabetes, heart
failure, IHD, obesity-hypoventilation syndrome, metabolic syndrome
etc.
 Results of the sleep study
 History of previous surgeries, their anesthetic challenges, need for ICU
admission
 Current medications
 Patients scheduled for repeat bariatric surgery should be screened
preoperatively for long-term metabolic and nutritional abnormalities

35. Investigations…
 Recommended preoperative laboratory evaluations include
◦ fasting blood glucose, lipid profile
◦ electrolytes
◦ serum chemistries (to evaluate renal and hepatic function)
◦ complete blood count
◦ Serum ferritin, vitamin B12, thyrotropin, & 25-hydroxyvitamin D.
(Miller 7th edition- anesthesia for Bariatic Surgery)
 ABG measurements help evaluate ventilation, as well as the need for perioperative oxygen administration
and postoperative ventilation.
 Routine pulmonary function tests and liver function tests are not cost-effective in asymptomatic obese
patients
 Coaugulation profile ( liver problem, repeat surgery, orlistat)
 ECG, echocardiography
 Sleep study if suspected OSA
(Barash 6th edition, anesthesia and obesity)

36. Concurrent, Preoperative, and Prophylactic
Medications
 Patients' usual medications should be continued until the time of surgery,
with the possible exception of insulin and oral hypoglycemics
 Antibiotic prophylaxis is usually indicated
 Obesity itself does not increase the risk for aspiration. acid aspiration
prophylaxis, including H2 receptor agonists or proton pump inhibitors,
must be considered in patients with identifiable risk for aspiration
 Anxiolysis and prophylaxis against deep vein thrombosis (DVT) should be
addressed at premedication.

37. DVT consideration
 Morbid obesity is a major independent risk factor for sudden death from
acute postoperative pulmonary embolism.
 Subcutaneous heparin 5,000 IU administered before surgery and repeated every 8 to 12
hours until the patient is fully mobile reduces the risk of DVT
 LMWH can also be used
 Preoperative prophylactic placement of an inferior vena cava filter should be
considered in
 venous stasis disease
 BMI ≥60,
 truncal obesity and
 OSA

38. What Are the Risks?
MAJOR RISKS:
 Death (1% of patients die
within 30 days)
 Severe malnutrition
(anemia, PEM,
osteomalacia)
 Peritonitis (from leakage or
ruptures at staple sites) or
other infection
 Obstructions caused by
scar tissue in the stomach
or bowels
MINOR RISKS:
 Dumping Syndrome
(unpleasant but not harmful)
 Diarrhea and malodorous
gas production
 Lactose intolerance
 Hair loss (short-term post-
surgery)
 May have to eventually
undergo surgical revision
 Pain post-surgery

39. History of Bariatric Surgery
 Obesity surgery is not a new discipline.
 The earliest Bariatric procedure performed was in 1954 at Minnesota. The procedure
was Jejuno-ileal bypass.
 In 1966,Gastric Bypass was introduced as a surgical procedure for weight loss at the
University of Iowa.
 In 1977,Griffen reported the first Roux-en-Y Gastric Bypass.
 In 1980,surgeons with a more conservative approach developed the Vertical Banded
Gastroplasty.
 Other procedures with longer intestinal segment bypass were also introduced such as
Biliopancreatic Diversions. These complex procedures are recommended in super-obese
patients, i.e. BMI>60.

40. How does surgery work?
RESTRICTIVE - RESTRICT AMOUNT OF FOOD INGESTED
Decreases appetite/hunger
Early satiety
Behavior modification
Gastric Banding (Lap Band)
Roux-en Y Gastric bypass (RYGB)
Sleeve Gastrectomy
MALABSORPTIVE- LIMITS DIGESTION AND ABSORPTION
Decreases length of intestine exposed to digested food
25% of fat is absorbed
Behavior modification
Biliopancreatic Diversion, Duodenal Switch (BPD/DS)
ALL OPERATIONS CAN BE PERFORMED OPEN OR LAPAROSCOPICALLY

41. Laparoscopic vs Open
OPEN
 ↑ post op pain
 Longer hospitalizations
 ↑ wound complications
 Infection
 Hernias
 Seromas
 Return to work in 4-8 weeks
LAPAROSCOPIC
 ↓ post op pain
 Early mobility
 ↓ Wound complications
 2-3 day hospital stay
 Return to work in 1-3 weeks
1. Nguyen NT, et al. Accelerated growth of bariatric surgery with the introduction of minimally invasive surgery. Arch Surg 2005;140:1198-202.

42. Procedures that are solely restrictive by creating a small gastric pouch of volume 15 to 30 cc & a degree of
outlet obstruction leading to delayed gastric emptying. The goal is to reduce oral intake by limiting gastric
volume, produce early satiety, and leave the alimentary canal in continuity, minimizing the risks of
metabolic complications
1.VERTICAL BANDED GASTROPLASTY
2.ADJUSTABLE GASTRIC BANDING (LAGB )
3. SLEEVE GASTRECTOMY
4.GASTRIC PLICATION
5. INTRA GASTRIC BALLOON (GASTRIC BALLOON)
RESTRICTIVE PROCEDURES:

43. Malabsorption is achieved by creating a short gut syndrome and/or by accomplishing distal mixing of bile
and pancreatic juice with ingested nutrients thereby reducing absorption.. Some purely malabsorptive
operations are no longer recommended due to their potential hazard to cause serious nutritional
deficiencies.
1. BILIOPANCREATIC DIVERSION
2. THE JEJUNAL-ILEAL BYPASS
3. ENDOLUMINAL SLEEVE
MALABSORPTIVE PROCEDURES

44. MIXED PROCEDURES
1.GASTRIC BYPASS ROUX-EN-Y ( RYGBP)
2.SLEEVE GASTRECTOMY WITH DUODENAL SWITCH
3.IMPLANTABLE GASTRIC STIMULATION
The following procedures combine restrictive and malabsorptive approaches. By adding malabsorption,
food is delayed in mixing with bile and pancreatic juices that aid in the absorption of nutrients. The result
is an early sense of fullness, combined with a sense of satisfaction that reduces the desire to eat.

45. The stomach is partitioned along its axis with a non-
adjustable poly-urethane band and with linear &
circular staples to create a small upper stomach
pouch with a restrictive orifice to the rest of the
stomach.
No malabsorption of micro or macro nutrients is
expected.
No longer done was practiced in 1980.
Vertical Banded Gastroplasty (VBG)

46. ADJUSTABLE GASTRIC BANDING
(LAP BAND SURGERY/ LAGB)
Restrictive Procedure
The procedure was first performed by Cadiere in 1992 but
was made popular by Belachew and Legrand in 1993.
An inflatable silicone BAND is placed around the top
portion of the stomach, to form a small stomach pouch &
sewed .
This band is connected to a tube that leads to a port above
the abdominal muscles placed below the skin (FILL –
PORT).
During follow up visits, we inject or remove saline solution
to make the band tighter or looser.

47. Adjustable Gastric Band
• Induces weight-loss in 3 ways:
1. The small stomach pouch causes a sensation of fullness
2. Squeezing of the stomach pouch like an hour glass prolongs the sensation of fullness.
3. Suppresses appetite by central action.

48. How does the Band work?
Surgery Factors:
 Restriction of meal size
 Decreased appetite
Patient Factors:
 Decreased calorie intake
 Increased calorie expenditure

49. LAP-BAND Adjustability
Unfilled Band Filled Band

50. Adjustments are made in the office

51. Complications of Gastric Lap-Band
• Perforation of Stomach
• Slippage
• Gastric Erosion(much less after Pars flaccida technique)
• Dilated Esophagus
• Tubing / access port problems
• Mal positioning
• Abdominal Pain
• Heartburn
• Vomiting
• Inability to Adjust the Band
• Failure to Lose Weight
• Infection of System
• Fatigue or malfunction

52. Advantages
 No intestinal surgery
 No stapling/cutting of stomach
 No nutritional risks
 Adjustable
 Reversible
 Safe
 Foreign body
 Frequent follow-up visits
 Needs more commitment
 Easy to cheat
Disadvantages

53. Comparison of Adjustable Gastric Banding and
Vertical Banded Gastroplasty
Laparoscopic adjustable gastric
banding
 Reversible
 Adjustable
 Simpler to perform laparoscopically
 Sustained weight loss of >50% EBW >5 years
following surgery
 Complications: Gastric prolapse, band erosion,
rarely gastric perforation and access port
complications.
Vertical banded gastroplasty
 Irreversible
 Non adjustable
 Technically difficult by laparoscopy
 Weight loss of 25-50% EBW and weight gain
after 2-3 years
 Complications: suture line disruption, gastric
leak, weight gain.

55.  Originally used as the first-stage operation for a proposed biliopancreatic diversion with duodenal
switch in high-risk patients.
 The sleeve gastrectomy has caught on as a primary obesity treatment as surgeons are reporting weight
loss of 55% of excess body weight past 5 years in some patients.
 The sleeve gastrectomy is also known as the greater curvature gastrectomy, vertical or longitudinal
gastrectomy or Pylorus preserving ‘gastric tube creation’.
 Rapid and less traumatic operation
 Good resolution of co-morbidities and good weight loss.
 A further second surgical step is then easily feasible, if necessary.
SLEEVE GASTRECTOMY

56. SLEEVE GASTRECTOMY
 A sleeve gastrectomy involves resection of
approximately 80% of the greater curvature
side of the stomach.
 Smaller tubular gastric “sleeve” created
along the lesser curve that is based on the
lesser curvature blood supply.
 Ideal approximate capacity of the stomach
after the procedure is about 30- 60 ml pouch

57. 1.MECHANICAL RESTRICTION by reducing the volume of the stomach and
impairing stomach mobility. Also called ‘Food limiting’ operation.
2.HORMONAL MODIFICATION by removing a great part of the Ghrelin
(Hunger Hormone) production tissue.
(Ghrelin is a 28 amino-acid-peptide, secreted by the oxyntic glands of the gastric
fungus. It is a potent orexigenic (appetite-stimulating) peptide mediated by the
activation of its receptors in the hypothalamus or pituitary area.)
The gastric fundus contains 10 to 20 times more ghrelin per one gram of tissue than
the duodenum. In the SG, resection of the fundus removes the major portion of
ghrelin release, therefore, appetite decreases.
The sleeve gastrectomy (SG) induces weight loss by 2
mechanisms:

59. Intragastric balloon involves placing a deflated balloon
into the stomach, and then filling it to decrease the
amount of gastric space.
The balloon can be left in the stomach for a maximum of
6 months and results in an average weight loss of 5–
9 BMI over half a year.
Done endoscopically
The intragastric balloon may be used prior to another
bariatric surgery as a step-down procedure.
INTRA GASTRIC BALLOON

62.  The EndoBarrier gastrointestinal liner
mimics the effects of gastric bypass surgery.
 It’s designed to work by inserting a flexible
tube-like barrier into the duodenum & prox.
Jejunum..
 The barrier is placed endoscopically via the
mouth and thus helps patients to loose
weight by delaying digestion.
 .Has to be removed after 6 months
ENDO BARRIER LINER SYSTEM

63. B. MAL- ABSORPTIVE PROCEDURES
Malabsorptive surgeries rearrange and/or remove part of digestive system which then limits
the amount of calories and nutrients that body can absorb. Treatment with a large
malabsorptive component results in the most weight loss but tend to have slightly higher
complication rates.
1.JEJUNAL ILEAL BYPASS – no longer performed for high complication rates.
2.ILEAL TRANSPOSITION- New malabsoptive procedure on trial for
treatment of DM type 2 and metabolic disorders.

64. C. COMBINATION PROCEDURES
RESTRICTIVE + MALABSORBTIVE
1.LAP. GASTRIC BYPASS – ROUX-EN- Y – more malabsorption than the restrictive
2.MINI- GASTRIC BYPASS- mainly restrictive
3.DUODENAL SWITCH – the sleeve stomach is the restrictive portion &the intestinal
bypass (duodenal switch) is the malabsorptive component
When surgery combines both restrictive and malabsorptive techniques, it is know as a “combination”
procedure. Most types of bariatric surgery carry at least a small element of both components, but the
following surgeries achieve a notable portion of weight loss from each…

65. 1. LAP. GASTRIC BYPASS/ LGB
The Roux-en-Y gastric bypass
(known simply as the LRYGBP) is
the most commonly performed
procedure.
It primarily causes
weight loss by restricting the
food intake, however there is
more amount of mal absorption that
occurs with this operation.

66. GASTRIC BYPASS/
LRYGBP
•The stomach is stapled into2
pieces, one small and one large. The
small piece becomes the “new”
stomach pouch.
• The larger portion of the stomach
stays in place, however will lie
dormant for the remainder of the
patient’s life.

67. GASTRIC BYPASS/ LGB
• The small intestine (the jejunum) is
divided using a surgical stapler
Approx. 50-70 cm from the DJ Junction.

68. GASTRIC BYPASS/ LGB
Y- LIMB/ BP
LIMB
• The end of the Roux limb is then attached to the newly
formed stomach pouch which carries food to the distal
intestine.
• The Roux loop is completed by forming a jejunostomy.
• The Y limb or BPD limb carries digestive juices from
the pancreas, gall bladder, liver and duodenum to the
intestines
• The food and the digestive juices mix where the Roux
limb and Y limb meet much below say 100-150 cm from
DJ
Roux limb or alimentary limb
100-150 cm

70. How Does the Roux-en-Y Work?
 Surgery factors:
 restriction of meal size
 “dumping syndrome”
 some malabsorption
 decreased appetite
 Patient factors:
 calorie intake
 calorie expenditure

71. • Most commonly performed.
• Most reliable operation for long term weight loss.
• Long term weight loss averages 60 to 75 percent of EBW.
• Malnutrition is unusual.
• Substantial improvement & resolution in many co-morbid
obesity conditions:
ADVANTAGES OF RYGBP

72. 1. Not reversible.
2. Mortality 0.5- 1%
3. Perioperative complications 5-10%
4. Stricture of gastrojejunostomy.-10% (long term)
5. Long term risk of protein & vitamin deficiency, and marginal ulceration of GJA.
6.Long term risk of intestinal obstruction – 2%.
LAPAROSCOPIC GASTRIC BYPASS
COMPLICATIONS

73. Biliopancreatic Diversion (BPD)
 Primarily malabsorptive but restrictive component also.
 First Terminal ileum is measured to a length of 50 cms, marked with
suture.
 The alimentary tract beyond the proximal part of stomach is rearranged to
include only distal 200 cm of ileum including common channel
 Common channel-Distal 50 cm of terminal ileum for absorption of fat and
protein.
 The proximal end of ileum anastomosed to proximal end of stomach after
performing distal hemigastrectomy.

74. Biliopancreatic Diversion with Duodenal Switch
 Modification to lessen high incidence of vit b12 deficiency, anastomotic
stricture at gastrojejunal anastomosis.
 This procedure involves a sleeve gastrectomy that is then diverted at the
duodenum into the ileum at a point measured proximally from the ileocecal
valve (usually 250 cm).
 The distal duodenum and jejunum, the biliopancreatic limb, are then
anastomosed to the ileum at a point measured proximally from the ileocecal
valve (usually 100 cm).
 Common channel is 100cm
 Entire alimentary tract is 250 cm.
 This is the most aggressive bypass procedure commonly offered today.
 Major difference-Sleeve gastrectomy instead of distal hemigastrectomy.

75. • Most women regained normal menstrual function and most had documented
spontaneous ovulation.
• Significant improvement in hirsutism, androgen profiles and about a 50% reduction in
HOMA-IR.
• Follow up for more than 2 years showed that all women resumed normal menstrual
cycles, HbA1C decreased from 8.2% to 5.1% in < 3 months.
• 78% saw improvement in metabolic syndrome & 48% showed improvement in PCOS .
2. ROLE OF BARIATRIC
SURGERY IN PCOS PATIENTS

76. • Decrease menstrual irregularities.
• PCOS women have less hyper androgenism
• Sex hormone binding globulin increases
• LH and FSH levels have been reported to increase
• Ovulatory function measured by luteal LH and Progesterone secretion improved .
• Leptin levels decrease , reflecting improved reproductive metabolic status.
• Subclinical hypothyroidism significantly reduced.
THE SAFE TIMING OF PREGNANCY
optimal or minimal time: >12 months after bariatric surgery before becoming pregnant in order to allow the rapid
weight loss and metabolic changes to subside.
4. BARIATRIC SURGERY IN
REPRODUCTIVE WOMEN:

77. Bariatric surgery represents the main option for substantial and long-term weight loss
in morbidly obese subjects..
Two hypotheses have been proposed to explain the early effects of bariatric surgery
on diabetes--
The Hindgut hypothesis theory- Diabetes control results from the more rapid delivery
of nutrients to the distal small intestine, thereby enhancing the release of hormones
such as glucagon-like peptide-1 (GLP-1).
The foregut hypothesis theory – Exclusion of the proximal small intestine reduces or
suppresses the secretion of anti-incretin hormones, leading to improvement of blood
glucose control as a consequence increases GLP-1 plasma levels which stimulate beta
cells to produce insulin secretion and suppress glucagon secretion, thereby improving
glucose metabolism.
Effect of Bariatric Surgery on Diabetes Mellitus

78. Combined Gastric Restriction & Malabsorption
 Operative Risks: (vs. cholecystectomy)
Perioperative Mortality 1-2% vs. 0.2-0.8% Early Complications
10% vs. 2.9%
Late Complications 20% vs. 1-2%
 Limitations:
Widening of (unbanded) gastrojejunostomy
Expansion of gastric pouch
25% with nearly 100% weight regain***
Adaptation of limb that receives the food

79. SUMMARY OF ALL TYPES OF SURGERY
• LRYGBP – worlds best procedure, 60-70% WL, dumping syndrome, malnutrition.
• LAGB- low complications, varying range of wt. loss, frequent post-op visits ( 10)
• DS/BPD- more wt. loss , high complications, good for high BMI > 50, malabsorption +
• VBG(vertical band gastroplasty) – longest available results, good wt. loss, improved co-morbidities,
right for some pts.risks too high to justify rewards
• SG- needs long term research, 1st step procedure, low risks, higher wt. loss, lesser complications, pouch
could Stretch over time, long staple line could cause problems in future, frequency is accelerating because
of technical ease, 1st stage procedure before bypass

80. Post-surgical Complications
 Anastomosis leaks or staple line leaks
 Pulmonary Embolism or DVT
 Cholelithiasis
 Stomal ulceration
 Dumping syndrome
 Constipation

81. Anastamosis Leaks
 Up to 7-10 days after surgery
 Most common at gastrojejunostomy, enteroenterostomy, Roux
limb stump, staple line
 Can lead to peritonitis, sepsis, possible death
 Presentation
 Tachycardia, tachypnea
 Fever
 Ab pain/back pain
 Pelvic pressure or rebound tenderness

82. Anastamosis Leaks
 Order Gastrograffin upper GI series
 Subclinical cases
 Bowel rest
 Parenteral nutrition
 IV antibiotic if H. pylori
 Clinically suspect leak
 Laparoscopic evaluation and leak repair
Failure to evaluate is the most common cause of preventable, major long-term disability or death in
bariatric surgical patients

83. Pulmonary Embolism
 Sudden cause of death up to one month after surgery
 20%-30% mortality rate
 High risk may have vena cava filter placement prior to surgery
 Prophylaxis with compression stockings and LMWH
 Early ambulation imperitive

84. Pulmonary Embolism
 Presentation
 Profound hypoxia
 Hypotension
 Signs of sepsis
 Immediate spiral chest CT
 Abdominal exploration if too large for machine
 No pathology start anticoagulation
 Too large…….NO SURGERY

85. Cholelithiasis
 Up to 36% of patients within 6 months post-op
 Bile stasis leads to increased sludge and gallstones
 Prophylactic cholecystectomy prior to surgery if
evidence of existing sludge or stones
 Prevent post-operative disease with concurrent bariatric
surgery and cholecystectomy
 Prophylactic use of urosidol
 Expensive and unpalatable

86. Stomal Ulceration
 12%-15% within 2-4 mos. Post-surgery
 Etiology
 Overabundant acid in pouch leads to excessive acid
passing through stoma
 Pouch tension and staple line breakdown
 NSAID use
 Presentation
 Dyspepsia, vomiting
 Epigastric or retrosternal pain

87. Stomal Ulceration
 Treatment
 PPI, carafate
 Antibiotics if H. Pylori
 Avoid NSAIDS, alcohol, smoking
 If no response to treatment
 Endoscopy
 Back to surgery for pouch revision or staple line repair

88. Dumping Syndrome
 More than 15% patients
 Hypotention
 Tachycardia
 Lightheadedness, syncope
 Flushing
 Abdominal cramping and diarrhea
 Nausea and vomiting

89. Dumping Syndrome
 Occurs with high dose simple sugar ingestion
 Sugar in small intestine causes osmotic overload and fluid
shift from blood to intestine
 Increased intestinal volume leads to watery diarrhea
 Decreased blood volume leads to systemic changes
 Patient education
 Eat slowly
 Avoid drinking before, during and not until 30 minutes after meals.

90. Constipation
 Most common complaint
 Causes
 Dehydration and decreased fluid intake post-operatively
 Increased metabolic water needs
 Calcium and iron supplement use following surgery
 Treat with increased fluids and stool softeners

91. Nutritional Consequences
 Iron deficiency anemia
 B12 deficiency
 Folate deficiency
 Calcium and Vitamin D deficiency
 Not seen with purely restrictive surgeries

92. Iron deficiency and anemia
 Common following RYGB
 As high as 49% of patients
 Multifactorial cause
 Low gastric acid levels prohibit iron cleavage from food
 Absorption inhibited because no nutrient exposure to duodenum or
proximal jejunum
 Decrease in iron-rich food consumption due to intolerance
 Treat with oral supplementation of ferrous sulfate or ferrous
gluconate

93. Vitamin B12 deficiency
 Up to 70% of patients
 Lack of hydrochloric acid and pepsin in stomach
 Prevents B12 cleavage from food
 Affects secretion of intrinsic factor, thus B12 absorption
 Intolerance to meat and milk
 Oral supplementation usually adequate, otherwise, IM injections used

94. Folate Deficiency
 40% of gastric bypass patients
 Complete absorption requires B12
 Absorption dependent on HCl and upper 1/3 stomach
 Deficiency generally caused by decreased consumption
 Oral supplementation

95. Vitamin D and Calcium Deficiency
 Vitamin D deficiency is common among obese people
 Calcium absorption decreased because duodenum is
bypassed
 Intolerance to dairy, foods high in calcium
 Vitamin D is required for Ca++ absorption
 Prolonged deficiencies lead to
 Bone resorption, osteomalacia, osteoporosis
 Treat with calcium citrate supplementation and 2 weekly
doses of Vitamin D

96. Nutritional Implications of Various Bariatric
Surgeries(3,4)
• RYGB
▫ Malabsorption of Vit B12, Vit B1 (thiamin), Vit D, Vit K, Folate, Iron, Calcium
• LAGB
▫ Folic Acid deficiency
• BPD and BPD/DS
▫ Vit A, D, E, and K deficiency, Protein-Calorie Malnutrition, Malabsorption of Calcium,
Zinc, Selenium, Sodium, Potassium, Chloride, Phosphorus, Magnesium

97. Recommended Daily Supplements(4)
 Multivitamin with iron (prenatal vitamin will have adeq amount of folic acid)
 Calcium (citrate) with vitamin D (1200-1500 mg calcium with 800-1000 IU
vitamin D)
 Oral vitamin B12 (500-1000 mcg)
 Iron (65 mg/day in elemental form)
 Vitamin C (to increase absorption of Iron)
 Thiamin (10 mg/day)

98. Diet Recommendations(3)
 Reduce food volume
 Chew food very well
 Slow pace of eating
 No liquids with meals
 Encourage fruits and vegetables as diet progresses
 Include high protein foods (at least 60g/day); may need protein supplements

99. Diet Progression: Gastric Bypass
 Stage 1: Clear liquids and protein supplement.
(1 week)
 Stage 2:No concentrated sweets, low fat puree diet ( 3 weeks)
 Stage 3: Regular texture weight reduction diet.

100. Diet Progression: Lap - Band
 Stage 1: Clear liquids and protein supplement.
( 2 weeks)
 Stage 2: No concentrated sweets, low fat puree diet (2weeks)
 Stage 3: Regular texture weight reduction diet.

101. Stage 1
 Only clear liquids allowed
 Avoid sweetened beverages
 Sip very slowly
 No straws
 Avoid caffeinated, carbonated and alcoholic beverages
 STOP drinking if you feel fullness, pain or discomfort

102. Protein supplements
 Begin the day after you go home from Hospital
 Minimum protein target 70gms/day
 May use powder or pre-mixed liquid forms (Whey protein is preferred)
 Protein pills may not be used

103. Vitamin and Mineral Supplements
Gastric bypass patients
 In addition to eating much less food gastric bypass patients will also absorb
vitamins and minerals differently after surgery.
 They will require daily multivitamin , calcium and iron supplementation for the
rest of your life

104. Vitamin and Mineral Supplements
Lap-Band® patients
Require a multivitamin with minerals daily
It may be necessary to take additional vitamins
and minerals e.g. calcium, iron, folate,B1,
B12.These will be prescribed as needed.

105. Stage 2 diet
PUREE

106. Puree diet
 Regular scheduled meals
 Avoid meal skipping
 Plan meals in advance
 Eat Slowly
 Eat protein foods first
 Moisten meats
 Use liquid protein as supplement not as
meal replacement
 Measure 2 oz portions at each meal.
 eating when full
 Separate liquids and solids
 No bread, rice or pasta
 Avoid added sugars and high fat foods
 VARIETY!

107. Stage 3 diet
NO CONCENTRATED SWEETS, LOW FAT, CALORIE CONTROLLED DIET

108. Stage 3 diet
 Continue to eat blended food, adding one new solid
food at a time
 Dice meats
 Chew slowly
 Food intolerances vary
 Prioritize protein rich foods
 Daily MVI, calcium and iron
 Gradually increase meal size to 4-5 oz

109. Stage 3 continued
Avoid meal skipping
Continue to separate liquids and solids
Protein intake assessed and supplement will be
adjusted/eliminated accordingly

110. Common post-operative nutritional problems
 Nausea
 Vomiting
 Dehydration
 Frothing
 Diarrhea
 Dumping Syndrome
 Dizziness
 Bad Breath
 Loss of appetite
 Food getting”stuck”
 Hair Loss
 Lactose intolerance
 Vitamin/mineral deficiencies
 Protein malnutrition
 Food intolerances
 Food aversions/fears
 Depression: often caused by frustration
around inability to eat for comfort/stress
 “Hibernation “ Syndrome

111. Late post –operative complication
Weight Gain
 Grazing
 Snacking on left –over meals
 Hidden calories
 Alcohol
 Poor food choices
 Carbonated beverages
 Lack of exercise
 Failure to check weight regularly
 Not attending follow up visits with Bariatric Surgeon

112. Post-Op Monitoring
Follow-up Lab Tests
Every 3 months for the first
year
CBC, glucose, creatinine
Every 6 months for the first
year
LFTs, protein and albumin, iron, TIBC, ferritin, vitamin B12, folic
acid, calcium, parathyroid hormone (if hypercalcemic)
Every year after the first year All of the above

113. Importance of Aftercare
 Surgery is only the beginning
 Initially the “full time job” is learning to eat
 Team approach to follow up: you are an important player
 Primary goal is to maintain good nutrition
 “Keep folks on the road”

114. Long-Term Complications
Side Effects – Skin Issues
 Severe infection of the excess abdominal skin
 Treat with antibiotics and skin hygiene
 Consider excision of the excess skin

115.  The most common areas subject to plastic surgery procedures are the abdomen,
thighs and buttocks.
 These areas are very susceptible to treatment with a combination of liposuction
and body lifting procedures.
 When the face and the neck are involved, the surgical corrections follow the
same principle of lifting/tightening the skin and subdermal tissues
 Mastopexy, or breast lift, is also a very common procedure as patients almost
universally complain of ptosis and atrophy of the mammary tissue.

116. Success of Surgical Treatment
ASBS 2000

117. Conclusion
 Bariatric surgery is the only effective long term treatment for morbid obesity
 Evidence for its initial & medium term success is overwhelming
 Extension of principles of surgery for obesity to other metabolic conditions
especially type2 DM, will increase its usage.
 There is no ideal bariatric surgery as it varies from patient to patient, no long term
studies.
 Newer techniques for performing this type of surgery promise to offer less
complications, less invasive surgery & better outcomes.

118. Thank You