A complete reference to a surgery that to be considered to treat obese Situations.

1. Bariatric surgery (weight loss surgery) includes a variety of procedures
performed on people who have obesity. Weight loss is achieved by reducing the size of
the stomach with a gastric band through removal of a portion of the stomach (sleeve gastrectomy
or biliopancreatic diversion with duodenal switch) or by resecting and re-routing the small
intestine to a small stomach pouch (gastricbypasssurgery).
Indications
"Surgeryshouldbe consideredasatreatmentoptionforpatientswithaBMI of 40 kg/m2 or greater
whoinstitutedbutfailedanadequate exercise anddietprogram(withorwithoutadjunctive drug
therapy) andwhopresentwithobesity-relatedcomorbidconditions,suchashypertension,impaired
glucose tolerance,diabetesmellitus,hyperlipidemia,andobstructive sleepapnea.A doctor–patient
discussionof surgical optionsshouldinclude the long-termside effects,suchaspossibleneedfor
reoperation,gallbladderdisease,andmalabsorption.
Classifications of surgical Procedures
Procedures can be grouped in three main categories
1. Predominantly malabsorptive procedures
In predominantly malabsorptive procedures, although they also reduce stomach size, the
effectiveness of these procedures is derived mainly from creating a physiological condition of
malabsorption.
1.1 Biliopancreatic diversion
Thiscomplex operationistermedbiliopancreaticdiversion(BPD) orthe Scopinaroprocedure.The
original formof thisprocedure isnowrarelyperformedbecauseof problemswithmalnourishment.
It has beenreplacedwithamodificationknownasduodenalswitch(BPD/DS).Partof the stomachis
resected,creatingasmallerstomach(howeverthe patientcaneata free dietasthere isno
restrictive component).The distal partof the small intestineisthenconnectedtothe pouch,
bypassingthe duodenumandjejunum.

2. In around2% of patientsthere issevere malabsorptionand
nutritional deficiencythatrequiresrestorationof the normal absorption.The malabsorptiveeffectof
BPD isso potentthat those whoundergothe procedure musttake vitaminanddietaryminerals
above andbeyondthat of the normal population.Withoutthesesupplements,there isriskof serious
deficiencydiseasessuchasanemiaandosteoporosis.
1.2 Jejunoileal bypass
Thisprocedure isno longerperformed.Itwasa surgical weight-lossprocedureperformedforthe
relief of morbidobesityfromthe 1950s throughthe 1970s inwhichall but 30 cm (12 in) to 45 cm (18
in) of the small bowel wasdetachedandsettothe side.
1.3 Endoluminal sleeve
A studyon humanswasdone inChile usingthe same technique howeverthe resultswere not
conclusive andthe device hadissueswithmigrationandslipping.A studyrecentlydone inthe
Netherlandsfoundadecrease of 5.5 BMI pointsin3 monthswithan endoluminal sleeve.
2. Predominantly restrictive procedures
Procedures that are solely restrictive act to reduce oral intake by limiting gastric volume, produce
early satiety, and leave the alimentary canal in continuity, minimizing the risks of metabolic
complications.
2.1 Vertical banded gastroplasty
In the vertical bandedgastroplasty,alsocalledthe Masonprocedure orstomachstapling,apart of
the stomach ispermanentlystapledtocreate asmallerpre-stomachpouch,whichservesasthe new
stomach.

3. 2.2 Adjustable gastric band
The restrictionof the stomachalso can be createdusinga silicone band,whichcanbe adjustedby
additionorremoval of saline throughaport placedjustunderthe skin.Thisoperationcanbe
performedlaparoscopically,andiscommonlyreferredtoasa "lap band".Weightlossis
predominantlydue tothe restrictionof nutrientintakethatiscreatedbythe small gastric pouchand
the narrow outlet.Itisconsideredone of the safestproceduresperformedtodaywithamortality
rate of 0.05%.
2.3 Sleeve gastrectomy
Sleeve gastrectomy,orgastricsleeve,isasurgical weight-lossprocedureinwhichthe stomachis
reducedtoabout 15% of itsoriginal size,bysurgical removal of alarge portionof the stomach,
followingthe majorcurve.The openedgesare thenattachedtogether(typicallywithsurgical
staples,sutures,orboth) toleave the stomachshapedmore like atube,ora sleeve,withabanana
shape.The procedure permanentlyreducesthe size of the stomach.The procedure isperformed
laparoscopicallyandisnotreversible.Thiscombinedapproachhastremendouslydecreasedthe risk
of weightlosssurgeryforspecificgroupsof patients,evenwhenthe riskof the twosurgeriesis
added.Most patientscanexpecttolose 30 to 50% of theirexcessbodyweightovera6–12 month
periodwiththe sleevegastrectomyalone.The timingof the secondprocedurewillvaryaccordingto
the degree of weightloss,typically6– 18 months.
2.4 Intragastric balloon (gastric balloon)

4. Intragastricballooninvolvesplacingadeflatedballoonintothe stomach,andthenfillingitto
decrease the amountof gastric space.The ballooncanbe leftinthe stomachfor a maximumof 6
monthsand resultsinanaverage weightlossof 5–9 BMI overhalf a year.The intragastricballoonis
approvedinAustralia,Canada,Mexico,India,UnitedStates(receivedFDA approval in2015) and
several EuropeanandSouthAmericancountries.The intragastricballoonmaybe usedpriorto
anotherbariatricsurgeryin order to assistthe patienttoreach a weightwhichissuitable forsurgery,
furtheritcan alsobe usedon several occasionsif necessary.
2.5 Gastric placation
Basically,the procedure canbestbe understoodasa versionof the more populargastricsleeve or
gastrectomysurgerywhere asleeve iscreatedbysuturingratherthanremovingstomachtissue thus
preservingitsnatural nutrientabsorptioncapabilities.Gastricplicationsignificantlyreducesthe
volume of the patient'sstomach,sosmalleramountsof foodprovide afeelingof satiety.The
procedure isproducingsome significantresultsthatwere publishedinarecentstudyinBariatric
Timesandare basedon post-operative outcomesfor66 patients(44 female) whohadthe gastric
sleeve plicationprocedure betweenJanuary2007 and March 2010. Mean patientage was34, witha
meanBMI of 35. Follow-upvisitsforthe assessmentof safetyandweightlosswere scheduledat
regularintervalsinthe postoperative period.Nomajorcomplicationswere reportedamongthe 66
patients.Weightlossoutcomesare comparable togastricbypass.
The study describesgastricsleeve plication(alsoreferredtoasgastricimbricationorlaparoscopic
greatercurvature plication) asa restrictive techniquethateliminatesthe complicationsassociated
withadjustable gastricbandingandvertical sleevegastrectomy—itdoesthisbycreatingrestriction
withoutthe use of implantsandwithoutgastricresection(cutting) andstaples.
3. Mixed procedures
Mixed procedures apply both techniques simultaneously.
3.1 Gastric bypass surgery
A commonformof gastricbypasssurgeryis the Roux-en-Ygastricbypass,whereasmall stomach
pouchis createdwitha staplerdevice andconnectedtothe distal small intestine.The upperpartof
the small intestineisthenreattachedinaY-shapedconfiguration.Thegastricbypasshadbeenthe
mostcommonlyperformedoperationforweightlossinthe UnitedStates,andapproximately
140,000 gastricbypassprocedureswere performedin2005. Its marketshare has decreasedsince
thenand by2011, the frequency of gastricbypasswasthoughtto be lessthan50% of the weightloss
surgerymarket.A factorinthe successof any bariatricsurgeryisstrict post-surgical adherence toa
healthypatternof eating.Thereare certainpatientswhocannottolerate the malabsorptionand
dumpingsyndrome associatedwithgastricbypass.Insuchpatients,althoughearlierconsideredto

5. be an irreversibleprocedure,there are instanceswhere gastricbypassprocedurecanbe partially
reversed.
3.2 Sleeve gastrectomy with duodenal switch
A variationof the biliopancreaticdiversionincludesaduodenal switch.The partof the stomach
alongitsgreatercurve isresected.The stomachis"tubulized"witharesidual volumeof about150
ml.Thisvolume reductionprovidesthe foodintake restrictioncomponentof thisoperation.This
type of gastric resectionisanatomicallyandfunctionallyirreversible.The stomachisthen
disconnectedfromthe duodenumandconnectedtothe distal partof the small intestine.The
duodenumandthe upperpart of the small intestine are reattachedtothe restat about75–100 cm
fromthe colon.
3.3 Implantable gastric stimulation
Thisprocedure where adevice similartoa heart pacemakerisimplantedbyasurgeon,withthe
electrical leadsstimulatingthe external surface of the stomach,isbeingstudiedinthe USA.Electrical

6. stimulationisthoughttomodifythe activityof the entericnervoussystemof the stomach,whichis
interpretedbythe braintogive a sense of satiety,orfullness.Earlyevidence suggeststhatitisless
effectivethanotherformsof bariatricsurgery.
Eating after bariatric surgery
Immediately after bariatric surgery, the patient is restricted to a clear liquid diet, which includes
foods such as clear broth, diluted fruit juices or sugar-free drinks and gelatin desserts. This diet is
continued until the gastrointestinal tract has recovered somewhat from the surgery. The next
stage provides a blended or pureed sugar-free diet for at least two weeks. This may consist of
high protein, liquid or soft foods such as protein shakes, soft meats, and dairy products. Foods
high in carbohydrates are usually avoided when possible during the initial weight loss period.
It is very common, within the first month post-surgery, for a patient to undergo volume depletion
and dehydration. Patients have difficulty drinking the appropriate amount of fluids as they adapt
to their new gastric volume. Limitations on oral fluid intake, reduced calorie intake, and a higher
incidence of vomiting and diarrhea are all factors that have a significant contribution to
dehydration. In order to prevent fluid volume depletion and dehydration, a minimum of 48–64 fl
oz should be consumed by repetitive small sips all day.
Effectiveness of surgery
WeightLoss - The maximum weight loss occurs in the first 10 months after surgery. More recent
studies have demonstrated that the medium (3–8 years) and long term (> 10 years) weight loss
results for RYGB and LAGB become very similar.However, the range of excess weight loss for
LAGB patients (25% to 80%) is much broader than that of RYGB patients (50% to 70%). Data
(beyond 5 years) for sleeve gastrectomy indicates weight loss statistics similar to RYGB.
Reduced mortality and morbidity
In the short term, weight loss from bariatric surgeries is associated with reductions in some
comorbidities of obesity, such as diabetes, metabolic syndrome and sleep apnea, but the benefit
for hypertension is uncertain. It is uncertain whether any given bariatric procedure is more
effective than another in controlling comorbidities. There is no high quality evidence concerning
longer-term effects compared with conventional treatment on comorbidities
Psychiatric/Psychological
Some studies have suggested that psychological health can improve after bariatric surgery.

7. Costs of Surgery
The costs of bariatric surgery depend on the type of procedure performed and method of
payment along with location-specific factors including geographical region, surgical practice and
hospital in which the surgery is performed.
The four established procedure types, Roux-en-Y gastric bypass, gastric banding, vertical sleeve
gastrectomy (gastric sleeve) and duodenal switch, carry an average cost in India of Rs 15 lakhs,
Rs 9 Lakhs , Rs 12 Lakhs and Rs 16 lakhs approximately respectively. However, location-
specific costs can vary significantly. Quoted costs generally include day-of-surgery fees for the
hospital, surgeon, surgical assistant, anesthesia and implanted devices (if applicable).
Depending on the surgical practice, quoted costs may or may not include pre-op, post-op or
longer-term follow-up office visits.
Adverse effects
Complicationsfromweightlosssurgeryare frequent.A studyof insurance claimsof 2522 whohad
undergone bariatricsurgeryshowed21.9% complicationsduringthe initial hospital stayanda total
of 40% riskof complicationsinthe subsequentsix months.Thiswasmore commoninthose over40
and ledtoan increasedhealthcare expenditure.Commonproblemswere gastricdumpingsyndrome
inabout 20% (bloatinganddiarrheaaftereating,necessitatingsmall mealsormedication),leaksat
the surgical site (12%),incisional hernia(7%),infections(6%) andpneumonia(4%) where the
mortalitywas0.2%. Asthe rate of complicationsappearstobe reducedwhenthe procedure is
performedbyanexperiencedsurgeon,guidelinesrecommendthatsurgerybe performedin
dedicatedorexperiencedunits.Ithasbeenobservedthatthe rate of leakswasgreaterinlow volume
centreswhereashighvolumecentresshowedalesserleakrate.Leakrateshave now globally
decreasedtoa meanof 1-5%.
Metabolicbone disease manifestingas osteopeniaandsecondaryhyperparathyroidismhave been
reportedafterRoux-en-Ygastricbypasssurgerydue toreducedcalciumabsorption.The highest
concentrationof calciumtransportersisinthe duodenum.Since the ingestedfoodwillnotpass
throughthe duodenumafterabypassprocedure,calciumlevelsinthe bloodmaydecrease,causing
secondaryhyperparathyroidism,increase inbone turnover,andadecrease inbone mass.Increased
riskof fracture has alsobeenlinkedtobariatricsurgery.
Rapidweightlossafterobesitysurgerycancontribute tothe developmentof gallstonesaswell by
increasingthe lithogenicityof bile.Adverse effectsonthe kidneyshave beenstudied.Hyperoxaluria
that can potentiallyleadtooxalate nephropathyandirreversiblerenal failure isthe mostsignificant
abnormalityseenonurine chemistrystudies.Rhabdomyolysisleadingtoacute kidneyinjury,and
impairedrenal handlingof acidandbase has beenreportedafterbypasssurgery.

8. Nutritional derangementsdue todeficienciesof micronutrientslike iron,vitaminB12,fatsoluble
vitamins,thiamine,andfolateare especiallycommonaftermalabsorptive bariatricprocedures.
Seizuresdue tohyperinsulinemichypoglycemiahave beenreported.Inappropriateinsulinsecretion
secondarytoisletcell hyperplasia,calledpancreaticnesidioblastosis,mightexplainthissyndrome.
Thiswill helpyoutoknowaboutthe surgerythatcan be possible consideredagainstObese
Situation.
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