Principles of Bariatric and Metabolic Surgery

Principles of
Bariatric Surgery
Dr Shahzad Alam Shah

Laparoscopic and Bariatric Surgeon
Fatima Jinnah Medical University
Learning objectives
■ What severe and complex obesity is

■ Rationale for surgery and the concept of metabolic surgery
■ Eligibility
■ Multidisciplinary assessment
■ The common operations and how they work
■ How to assess and treat perioperative complications
■ Follow-up, nutritional supplements and biochemical monitoring
What is Obesity?
■ Chronic, Relapsing, Multifactorial, Neurobehavioral disease

■ Resulting into
– deposition of increase in body fat that promote adipose tissue
dysfunction
– and adverse metabolic, biomechanical, and psychosocial health
consequences
INTRODUCTION
■ Bariatric surgery comes from the Greek baros: weight/pressure, and -iatric: the
medicine or surgery thereof
■ BARIATRICS
– Bariatrics is the branch of medicine that deals with the causes, prevention, and
treatment of obesity
■ BARIATRIC SURGERY
– Bariatric surgery is an operation that helps to lose weight by making changes to the
digestive system.
RATIONALE
■ Bariatric surgery leads to weight loss of 25–35% of body weight
■ Obesity-related diseases improve as weight is lost.
■ Quality of life improves
■ Leads to survival benefit (Swedish Obese Subjects (SOS))
METABOLIC SURGERY
■ Metabolic Syndrome
– Obesity with Type 2 diabetes is part of the ‘metabolic syndrome’ that includes high
blood pressure, dyslipidaemia and polycystic ovary syndrome.
The common operations
■ Gastric Banding
■ Sleeve Gastrectomy
■ R&Y Gastric Bypass
■ Mini Gastric Bypass/One Anastomosis Gastric Bypass
■ Biliopancreatic ByPass
■ Duodenal Switch
■ SASI
■ SADI
Gastric Banding
Sleeve Gastrectomy
■ The lesser curve-based gastric tube is
constructed over a size 32–36 Fr bougie,
■ Resected Stomach is removed from the
body
Roux-en-Y gastric bypass
■ Roux-en-Y gastric bypass includes a short
vertical lesser curvature-based gastric pouch.
■ Pouch Jejunostomt
■ Jejuno-Jejunostomy
Biliopancreatic Diversion and
BPD with Duodenal Switch
■ A sleeve gastrectomy is
followed by division of the
duodenum just distally to the
pylorus.
■ Duodenoileostomy and
ileoileostomy with the
objective to create a common
channel of 75–125 cm and an
alimentary channel of 100–
250 cm.
■ Types of Obesity
■ Multidisciplinary Assessment •
■ Preoperative Preparation of Patients
■ How to assess and treat perioperative complications •
■ Follow-up,
■ Nutritional supplements and
■ Biochemical monitoring
Defining Overweight and Obesity
Types of Obesity Android and Gynoid Obesity
Conditions associated with severe obesity
Multidisciplinary Assessment
Pre-operative Preparation of Bariatric
Patients
■ It is routine to put patients on a ‘liver shrinkage diet’ for at least 2 weeks before
surgery
■ Preoperative education sessions, best run by trained nurses and dietitians.
■ The ward and outpatient environment must be suitably equipped for severely
obese patients, to include scales that can measure up to 250 kg.
■ Pre-Operative Physiotherapy
■ Management of Comorbidities
■ Biochemical Assessment
■ Anticoagulant Therapy
Operative Technique
■ Laparoscopic Surgery
■ Patient positioning
■ Trocar Placement
■ Instrumentations
■ Insufflation
■ Use of Vessel Sealing Devices
■ Endo Stappling
■ Endo suturing
PROCEDURES—Laparoscopic
Approach
Outcomes and Advantages
■ Weight Loss:
– Total Body Weight Loss /
– Extra Body Weight loss
■ Metabolic Benefits
– Diabetes Type2
– Hypertension
– Dyslipidemias
■ PCOS and Infertility Improvement
■ Joint Pain Alleviation
■ Respiratory Disease Improvement
Outcomes
Outcomes
Complications of Bariatric Surgery
■ Port Site Infection
■ Intraabdominal Bleeding
■ Internal Herniation
■ DVT/PE
■ Malnutrition
■ Anastomotic Ulcer/stricture
■ GERD
■ Weight Regain
POST BARIATRIC SURGERY COMPLICATIONS
EARLY LATE
Which is the leading cause of mortality in
Bariatric Surgery
■ Anastomotic Leak
■ DVT/PE
■ Intraabdominal Bleeding
■ Malnutrition
■ Internal Herniation
■ Anesthesia Related Chest Complications
Prevention of DVT/Pulmonary Embolism
■ Preoperative Low Molecular

Weight Heparin (ENOXAPARIN)
■ Perioperative Intermittent
compression of Leg
■ Early mobilization after surgery

Prevention of Anesthesia Related Chest
Complications
■ Pulmonary Function Test

Assessment
■ Treatment of any acute or treatable
respiratory ailment
■ Incentive Spirometry
■ Post-Operative Chest Physiotherapy
Nutritional Deficiencies
■ Vitamins
– Vit B12
– VIT B6
– VIT D
– VIT A
■ Minerals
– Folate
– Serum Calcium
– Serum Ferritin
■ Protein Energy Malnutrition
Laparoscopic surgery and enhanced
recovery-- ERAS
■ It is usual for gastric bypass and sleeve gastrectomy patients to go home on
postoperative day 2 or 3.
■ Free access to fluids is routine immediately after surgery
■ Due to the relative lack of pain patients can mobilize straightaway
Follow Up
■ Assessment of Weight Loss

■ Dieticians assessment of post operative diet problems
■ Evaluation of the effect of Bariatric surgery on Metabolic Diseases
■ Assessment and Correction of Nutritional Deficiencies
Posttest-----------
■ At which BMI Bariatric Surgery is ■ AT BMI 40Kg/m2 or 35kg/m2 with co-
indicated morbidities
■ Metabolic Surgery
■ Bariatric surgery is also called -------------
■ Grehlin
■ Hormone secreted from the fundus of
Stomach is called--------------
■ Leptins, Grehlin, Insulin, GLP-I, CCK, PYY
■ Various peripheral Hormones that that
control the appetite and food are ----------
■ Which hormones are long term regulators ■ Leptins and Insulin
of energy balance
■ Which are restrictive bariatric surgery ■ Sleeve Gastrectomy, Gastric Banding
procedures
■ Name malabsobtive bariatric surgery ■ R&Y Gastric Bypass, BP Diversion, Duodenal
procedures Switch
QUESTIONS
■ What is Morbid Obesity?
■ What is Metabolic Syndrome?
■ How much approx. extra-body weight loss can be achieved after
sleeve gastrectomy?
■ GLP-I AND PYY are secreted from which organ?
■ Internal Herniation is a complication of which bariatric procedure?
■ Function of GLP-I is--------?
■ What measures should be taken to prevent Pulmonary Embolism?
After Gastric Bypass/ Metabolic Surgery
Bariatric surgery response in Younger Patients
What Procedure would you opt for this
patient?

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Principles of

Dr Shahzad Alam Shah

■ What severe and complex obesity is

■ Chronic, Relapsing, Multifactorial, Neurobehavioral disease

■ Preoperative Low Molecular

■ Early mobilization after surgery

■ Pulmonary Function Test

■ Assessment of Weight Loss

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